Sourcebook H Vol. 1 

Sourcebook: Women Veterans in 

the Veterans Health Administration

VOLUME 1:

Sociodemographic Characteristics and 

Use of VHA Care

Women’s Health Evaluation Initiative (WHEI)

Center for Health Care Evaluation

VA HSR&D Center of Excellence

VA Palo Alto Health Care System

Palo Alto, CA

Women Veterans Health Strategic Health Care Group 

Office of Public Health and Environmental Hazards

Veterans Health Administration

Washington, DC

December 2010

Women Veterans Sourcebook Vol. 1: Introduction 

01 

Since the Revolutionary War, America’s women 


have earned America’s gratitude and respect 


for their contributions to the military 


and to the Nation. VA will continue to improve 


our benefits and services for women Veterans as we 


transform into a 21st century organization.
 

Secretary of Veterans Affairs 


Eric K. Shinseki
 

March 10, 2010
 

Women Veterans Sourcebook Vol. 1: Introduction 

Sourcebook: Women Veterans in the
 

Veterans Health Administration (VHA)
 

Volume 1. Sociodemographic Characteristics 

and Use of VHA Care 

Prepared for: 

Women Veterans Health Strategic Health Care Group 

Office of Public Health and Environmental Hazards, Veterans Health Administration
 

Department of Veterans Affairs
 

810 Vermont Ave., NW
 

Washington, DC 20420
 

Prepared by: 

Women’s Health Evaluation Initiative (WHEI) 

Center for Health Care Evaluation
 

VA Palo Alto Health Care System
 

3801 Miranda Ave. (152-MPD)
 

Palo Alto, CA 94304
 

Susan M. Frayne, MD, MPH, Director, WHEI
 

Ciaran S. Phibbs, PhD, Associate Director, WHEI
 

Sarah A. Friedman, MSPH, Project Manager and Technical Writer
 

Eric Berg, MS, Senior Data Analyst
 

Lakshmi Ananth, MS, Senior Data Analyst
 

Samina Iqbal, MD, Senior Clinical Consultant
 

Patricia M. Hayes, PhD, Chief Consultant,
 

Women Veterans Health Strategic Health Care Group
 

Laura Herrera, MD, MPH, Acting Deputy Chief Officer, 


Office of Public Health and Environmental Hazards
 

Recommended citation: Frayne SM, Phibbs CS, Friedman SA, Berg E, Ananth L, Iqbal S, Hayes PM, Herrera L. Sourcebook: Women 


Veterans in the Veterans Health Administration. Volume 1. Sociodemographic Characteristics and Use of VHA Care. Women’s Health Evaluation 


Initiative, Women Veterans Health Strategic Health Care Group, Veterans Health Administration, Department of Veterans Affairs, 


Washington DC. December 2010.
 

Acknowledgements: Kerri Childress, MA, John Finney, PhD, Sally Haskell, MD, Geraldine McGlynn, MEd, John McKellar, PhD, 


Rudolf Moos, PhD, Maureen Murdoch, MD, MPH, Donna Washington, MD, MPH, Ellen Yee, MD, MPH, and Laurie Zephyrin, MD, 


MPH, MBA, FACOG, provided valuable editorial input. Kaajal Laungani, BS, Natalia Llarena, BA, and Xiaoyu Bi, PhD, provided key 


technical assistance. 


Our deepest gratitude goes to the women Veterans who have served our country across the generations. 

This report is based on program evaluation analyses conducted by the Women’s Health Evaluation Initiative at the VA Palo Alto Health 

Care System in Palo Alto, California. This work was funded by the Women Veterans Health Strategic Health Care Group of the Veterans 

Health Administration, Department of Veterans Affairs. The findings and conclusions reported in this document are those of the authors 

who are responsible for its contents, and do not necessarily represent the views of the Department of Veterans Affairs or the United States 

government. Therefore, no statement in this document should be construed as an official position of the Department of Veterans Affairs. 

Women Veterans Sourcebook Vol. 1: Introduction 

i 

EXECUTIVE SUMMARY.................................................................................................................................................................................................................................. 

INTRODUCTION............................................................................................................................................................................................................................................... 4 

Background .............................................................................................................................................................................................................................................. 4 

Methods .................................................................................................................................................................................................................................................. 

PART 1: SOCIODEMOGRAPHICS.................................................................................................................................................................................................................. 6 

Women Veteran VHA Patient Cohort Size........................................................................................................................................................................................... 6 

Ages of Women Veteran VHA Patients................................................................................................................................................................................................ 

Service-Connected Disability Status of Women Veteran VHA Patients........................................................................................................................................ 9 

PART 2: UTILIZATION OF VHA CARE.......................................................................................................................................................................................................... 12 

Women Veterans’ Utilization in FY09.................................................................................................................................................................................................. 12 

Outpatient Care......................................................................................................................................................................................................................... 12 

Primary Care.............................................................................................................................................................................................................................. 14 

Specialty Care for Women ...................................................................................................................................................................................................... 18 

Mental Health Care .................................................................................................................................................................................................................. 18 

Inpatient Admissions................................................................................................................................................................................................................ 20 

Women Veterans’ Longitudinal Trends, FY00–FY09 ......................................................................................................................................................................... 21 

Outpatient Care......................................................................................................................................................................................................................... 

Primary Care.............................................................................................................................................................................................................................. 

Specialty Care for Women ...................................................................................................................................................................................................... 23 

24 

................................................................................................................................................................................................................ 25 

ART 3: TECHNICAL APPENDIX 26 

1. Data Sources ............................................................................................................................................................ 26 

2. Cohort Creation ......................................................................................................................................................... 26 

3. Algorithms for Sociodemographic Characteristics ............................................................................................ 28 

4. Algorithms for Utilization 30 

5. Data Quality Control ........................................................................................................................................................................................................................ 34 

 

Table of Contents
 

EXECUTIVE SUMMARY ................................................................................................................................................................................................................................. 1
 

Key Findings ............................................................................................................................................................................................................................................ 2
 

Key Implications for Policy and Practice ............................................................................................................................................................................................ 3
 

INTRODUCTION............................................................................................................................................................................................................................................... 5
 

Background.............................................................................................................................................................................................................................................. 5
 

Methods ................................................................................................................................................................................................................................................. 6
 

PART 1: SOCIODEMOGRAPHICS ................................................................................................................................................................................................................. 7
 

Women Veteran VHA Patient Cohort Size........................................................................................................................................................................................... 7
 

Ages of Women Veteran VHA Patients................................................................................................................................................................................................ 8
 

Service-Connected Disability Status of Women Veteran VHA Patients...................................................................................................................................... 10
 

PART 2: UTILIZATION OF VHA CARE ......................................................................................................................................................................................................... 13
 

Women Veterans’ Utilization in FY09.................................................................................................................................................................................................. 13
 

Outpatient Care......................................................................................................................................................................................................................... 13
 

Primary Care.............................................................................................................................................................................................................................. 15
 

Specialty Care for Women ..................................................................................................................................................................................................... 19
 

Mental Health Care ................................................................................................................................................................................................................. 19
 

Inpatient Admissions ............................................................................................................................................................................................................... 21
 

Women Veterans’ Longitudinal Trends, FY00–FY09 ......................................................................................................................................................................... 22
 

Outpatient Care......................................................................................................................................................................................................................... 22
 

Mental Health Care Mental Health Care .................................................................................................................................................................................................................. .................................................................................................................................................................................................................. 25
 

Inpatient Admissions Inpatient Admissions ............................................................................................................................................................................................................... 26
 

PART 3: TECHNICAL APPENDIX................................................................................................................................................................................................................. ................................................................................................................................................................................................................. 27
 

1. Data Sources......................................................................... ..................................................................................................................................................................................................................................... 27
 

2. Cohort Creation........................................................................ ................................................................................................................................................................................................................................. 27
 

3. Algorithms for Sociodemographic Characteristics........................................................................ .................................................................................................................................................................... 29
 

4. Algorithms for Utilization ........................................................................ ................................................................................................................................................................................................................. ......................................................................................................................................... 31
 

Outpatient Utilization................................................................................................................................................................................................................ 31
 

Inpatient Utilization .................................................................................................................................................................................................................. 34
 

5. Data Quality Control.......................................................................................................................................................................................................................... 35
 

Table of Figures
 

PART 1
 

Figure 1. Number of women Veteran VHA patients in each year, FY00–FY09 ............................................................................................................................... 7
 

Figure 2. Number of men Veteran VHA patients in each year, FY00–FY09..................................................................................................................................... 7
 

Figure 3. Age distribution among women Veteran VHA patients, FY09.......................................................................................................................................... 8
 

Figure 4. Age distribution of women Veteran VHA patients (#), FY00 and FY09 ............................................................................................................................ 8
 

Figure 5. Age distribution of women Veteran VHA patients (%), FY00–FY09 ................................................................................................................................. 9
 

Figure 6. Age group of Veteran patients, by gender, FY09................................................................................................................................................................ 9
 

Figure 7. Service-connected disability status among women Veteran VHA patients, FY00 and FY09.................................................................................... 10
 

Figure 8. Service-connected disability status among women Veteran VHA patients, by age, FY09....................................................................................... 11
 

Figure 9. Service-connected disability status among Veteran VHA patients, by gender, FY09 ............................................................................................... 11
 
Women Veterans Sourcebook Vol. 1: Introduction 

ii 

 

 

PART 2
 

Figure 10. Proportion of women Veteran VHA patients by frequency of face-to-face outpatient visits, FY09 ...................................................................... 13
 

Figure 15. Proportion of women and men Veteran VHA outpatients by frequency of total primary care visits, by service-connected 


Figure 23. Proportion of women and men Veteran VHA outpatients by frequency of mental health visits, by service-connected 


Figure 11. Proportion of women and men Veteran VHA patients by frequency of face-to-face outpatient visits, FY09...................................................... 14
 

Figure 12. Proportion of women and men Veteran VHA patients by frequency of face-to-face outpatient visits, by age group, FY09............................ 14
 

Figure 13. Proportion of women and men Veteran VHA outpatients by frequency of total primary care visits, FY09.......................................................... 16
 

Figure 14. Proportion of women and men Veteran VHA outpatients by frequency of total primary care visits, by age group, FY09................................ 16
 

disability ratings, FY09........................................................................................................................................................................................................ 17
 

Figure 16. Proportion of women Veteran VHA outpatients by frequency of primary care clinic (PC) visits, FY09................................................................ 18
 

Figure 17. Proportion of women Veteran VHA outpatients by frequency of women’s health clinic (WHC) visits, FY09 ...................................................... 18
 

Figure 18. Proportion of women Veteran VHA outpatients by which primary care clinics they use, FY09 ............................................................................ 18
 

Figure 19. Proportion of women Veteran VHA outpatients by frequency of women’s health clinic (WHC) visits, by age group, FY09............................. 19
 

Figure 20. Proportion of women Veteran VHA outpatients by frequency of mental health visits, FY09.................................................................................. 19
 

Figure 21. Proportion of women and men Veteran VHA outpatients by frequency of mental health visits, FY09 ................................................................. 20
 

Figure 22. Proportion of women and men Veteran VHA outpatients by frequency of mental health visits, by age group, FY09........................................ 20
 

disability ratings, FY09........................................................................................................................................................................................................ 21
 

Figure 24. Proportion of women and men Veteran VHA patients with at least one inpatient stay, by age group, FY09 ...................................................... 22
 

Figure 25. Proportion of women and men Veteran VHA patients with at least one inpatient stay, by service-connected disability ratings, FY09........ 22
 

Figure 26. Number of women Veteran VHA patients by frequency of face-to-face outpatient visits, FY00–FY09 ................................................................ 23
 

Figure 27. Proportion of women Veteran VHA outpatients by frequency of total primary care visits, FY00–FY09................................................................ 23 


Figure 28. Proportion of women Veteran VHA outpatients by frequency of primary care clinic (PC) visits, FY00–FY09 ..................................................... 24
 

Figure 29. Proportion of women Veteran VHA outpatients by frequency of women’s health clinic (WHC) visits, FY00–FY09............................................ 24
 

Figure 30. Proportion of women Veteran VHA outpatients by frequency of mental health care visits, FY00–FY09.............................................................. 25
 

Figure 31. Proportion of women Veteran VHA patients with at least one inpatient stay, FY00–FY09...................................................................................... 26
 

List of Acronyms 

ADUSH................Assistant Deputy Under Secretary of Health 


FY ......................... Fiscal Year (October 1 to September 30)
 

HSR&D................Health Services Research and Development
 

GAO ..................... Government Accountability Office
 

IP.......................... Inpatient
 

MH.......................Mental Health
 

PC ....................... Primary care clinic
 

PTF....................... VHA inpatient stay files
 

SC ........................ Service-connected
 

SE/SF...................VHA outpatient encounter and visit files 


VBA ..................... Veterans Benefits Administration
 

VHA ..................... Veterans Health Administration
 

VIReC .................. VA Information Resource Center
 

VSSC ................... VHA Support Services Center
 

WHC .................... Women’s health clinic
 

WHEI ................... Women’s Health Evaluation Initiative
 

WV.......................Women Veterans
 

WVHSHG ............ Women Veterans Health Strategic Health Care Group
 
Women Veterans Sourcebook Vol. 1: Executive Summary 

Executive Summary 


Despite the fact that women have served in every United States military conflict since the American Revolution, 

they were not recognized as Veterans at the time that President Abraham Lincoln urged Congress to 

authorize Veterans benefits assistance “to care for him who shall have borne the battle, and for his widow, and his 

orphan.” Even when Congress granted women eligibility for Veterans Health Administration (VHA) care, women 

represented an extreme numeric minority group within an organization originally designed to meet the health care 

needs of men. 

Over the past two decades, VHA has rolled out numerous initiatives designed to improve access and quality of 

care for women Veterans. Since 2008, these efforts have been overseen nationally by the Women Veterans Health 

Strategic Health Care Group (WVHSHG). Along with clinical advances, VHA women’s health research has accelerated, providing an evidence base that further sharpens the focus on women Veterans. 

Although highly informative data on women Veterans are available from the research literature1

 and from various 

VHA reports (e.g., VHA Office of Policy and Planning, and the searchable VSSC Data Cube), the WVHSHG 

identified the need for detailed data specifically tailored to its strategic planning objectives. A bridge has been 

created between clinical leadership and research, linking the WVHSHG with women’s health investigators with 

expertise in large database research at the Center for Health Care Evaluation, a VHA Health Services Research 

& Development (HSR&D) Center of Excellence, and the Health Economics Resource Center at VA Palo Alto 

Health Care System. 

This Sourcebook (Volume 1) is the initial result of the collaboration between the WVHSHG and VA Palo Alto 

Health Care System. The first in a planned series of reports, this volume describes sociodemographic characteristics and health care utilization patterns of women Veteran patients in the VHA. Its primary purpose is to provide 

data to inform policy and program planning as VHA implements and evaluates new ways of providing care to 

women Veterans. 

All data in this report come from centralized, national VHA administrative databases of enrollment, outpatient 

care, and inpatient care. The report describes women Veterans receiving VHA care in Fiscal Year 2009 (FY09) 

overall, and within key subgroups (i.e., within age groups and service-connected disability status groups). It also 

presents gender comparisons between women and men in FY09. Finally, it presents longitudinal trends over the 

past decade (FY00–FY09). 

The report has several limitations: (1) The data represents only Veterans who chose to use VHA care, rather than 

all Veterans. The characteristics of Veterans who do not choose to use VHA could differ from the characteristics 

of those who do. (2) This report does not examine non-Veteran women who use VHA services.2

 (3) This report 

1 Goldzweig CL, Balekian TM, Rolon C, Yano EM, Shekelle PG. The State of Women Veterans’ Health Research. Results of a Systematic 

Literature Review. J Gen Intern Med. 2006;21(s3):S82-S92; Bean-Mayberry B, Batuman F, Huang C, Goldzweig CL, Washington 

DL, Yano EM, Miake-Lye I, Shekelle PG. A Systematic Review of the Literature on Women Veterans’ Health 2004–2008 Update, VA-ESP 

Project #05-226; 2010, http://.hsrd.research.va.gov/publications/esp/womens-health.pdf. 

2 See Technical Appendix, Section 3, for a more complete explanation of the types of non-Veteran women who use VHA services. 

1 
Women Veterans Soureterans Sourcebook Vol. 1: Executiol. 1: Executive Summarve Summary 

does not include race/ethnicity data among the sociodemographic information due to concerns about the quality 

of data for the race/ethnicity variable. (4) Utilization data include outpatient and inpatient VHA care, but do not 

include care provided by VHA through fee basis or contracts, and do not include non-VHA care received privately 

by women who use VHA. Thus, for women Veterans who use VHA for at least some of their care, total health care 

utilization across all systems of care is likely to be higher than the VHA-based utilization rates presented in this report. 

Key Findings 

Rapid Growth of VHA Women Veteran Population, FY00–FY09. The number of women Veterans using VHA has 

nearly doubled in the past decade, from 159,630 in FY00 to 292,921 in FY09. The rate of growth has been faster 

in women Veterans than in men Veterans. 

Shifting Age Distribution in VHA Women Veterans. In FY00, the age distribution of women showed two main 

peaks: The tallest peak had a maximum at age 44, and the second peak had a maximum at age 76. By FY09, this 

pattern had shifted. The peak that had been tallest in FY00 was even taller in FY09 and had its maximum at age 

47. The second peak had its maximum at age 85. Meanwhile, a substantial new third peak had appeared, with its 

maximum at age 27. 

High Levels of Service-Connected Disability Status in VHA Women Veterans. As of FY09, more than half of 

women Veteran patients in VHA had received a service-connected disability rating. The proportion of women 

Veterans receiving service-connected disability ratings increased over the decade. Further, in FY09, a higher proportion of women Veterans who were 18–44 years old had a service-connected disability rating than women who 

were 45–64 or 65–110 years old. 

Frequent Use of VHA Care by VHA Women Veterans. Among women Veterans who had any face-to-face outpatient visits with a clinician in FY09, VHA provided, on average, 12 face-to-face outpatient visits per woman, not 

including any services received through fee-basis care.3 

 

Ninety percent of women Veteran VHA patients had at least one primary care visit in FY09. Among primary care 

patients, women Veterans visited primary care clinics an average of 3.5 times in FY09. 

Among women Veteran VHA patients, 37% received mental health services in FY09; women who used mental 

health services visited mental health clinics an average of nine times in FY09. 

Increase in Women Veterans Using VHA Care, FY00–FY09. The proportion of all women Veteran VHA outpatients 

using primary care increased from 79% in FY00 to 90% in FY09. The proportion of all women Veteran VHA outpatients using mental health services increased from 28% in FY00 to 37% in FY09. However, the average number 

of visits for primary care and mental health services per women Veteran was relatively constant between FY00 and 

FY09. 

Gender Differences Among Veteran VHA Patients. Nearly 6% were women in FY09. Compared to men, women 

were, on average, substantially younger: 42% of women and 12% of men were less than 45 years old. Women 

were more likely than men to carry a service-connected disability status and to have a service-connected disability 

In all cases, outpatient utilization described in Part 2 of this report does not include “fee-basis,” contract care, or pharmacy services. See 

“Notes to Interpretation” on page 14 for an explanation of how this might underestimate total VHA outpatient utilization by women 

Veteran VHA patients. 

2 

3 
Women Veterans Soureterans Sourcebook Vol. 1: Executiol. 1: Executive Summarve Summary 

rating of at least 50 percent.4 Within every age group, a greater proportion of women than men used face-to-face 

outpatient services more than six times. Women used more primary care services than did men: 47% of women 

versus 42% of men had at least three primary care visits, and 15% of women versus 11% of men had at least six 

primary care visits in FY09. Women used more mental health services than did men. Among mental health clinic 

patients, 12% of women and 7% of men had more than six mental health visits in FY09. 

Key Implications for Policy and Practice 

•	 The number of women Veterans using VHA services has nearly doubled in the past decade. If growth 


continues at this pace, and especially if market penetration increases among the large group of women 


Veterans who currently do not use VHA,5

 increasing demands upon VHA delivery systems for women 


are anticipated. 


•	 The number of young women in VHA has been growing rapidly in recent years. This rapid demographic shift 

highlights the need to assure ample capacity for clinical services necessary for women in their reproductive 

years and to assure that health care providers’ knowledge and skills are up to date in this clinical domain. 

•	 The tallest peak in the age distribution of women Veteran patients was at age 47 in FY09. Twenty years from 

now, this large group of women will be nearing their seventies. These women could require more intensive 

health care services as they age, including geriatric and extended care services and, where applicable, support 

for their role as caregivers. Also, as these women become Medicare-eligible, coordination of care across health 

care systems may become increasingly important. 

•	 The proportion of women Veteran VHA patients with a service-connected disability rating, as well as the proportion with ratings of 50 percent or more, has increased over the decade. More than half of women Veterans 

in VHA now carry a service-connected disability rating, some of whom are very young. These women will be 

eligible for lifelong VHA care for their service-connected conditions. 

•	 Women Veterans use VHA primary care services even more heavily than do men Veterans. Clinicians with a 

large number of women in their panels may require adjustments in panel size or scheduling profiles to assure 

that women have sufficient access to care. 

•	 Among those women Veteran VHA patients who have mental illness, many use mental health services. Those 

who use mental health services tend to make many visits, suggesting that mental health care for women often 

requires high-intensity services. 

•	 The proportion of women Veteran VHA patients who made one or more primary care visits increased 

between FY00 and FY09. This suggests that the VHA has been successful in its efforts to connect more 

women Veteran patients with primary care providers. Further, the proportion of women Veteran VHA 

patients who had one or more mental health visits increased between FY00–FY09. This suggests that VHA 

innovations in the past 10 years, such as systematic screening for mental illness and embedded mental health 

providers in primary care settings, appear to have improved access to mental health services for women 

Veteran VHA patients. 

4	 To enhance the clarity and readability of this report, an editorial decision has been made to spell “percent” in reference to service-connected disability ratings, e.g. “SC disability rating of 70 percent.” In all other measures of percentage, the percent symbol (%) is used. 

5	 In FY09, WHEI data indicate that 292,921 women Veterans received VHA care. In that same year, there were approximately 

1,824,000 women Veterans living in the United States (based upon Vetpop data, accessed at http://www1.va.gov/vetdata/). Thus, the 

majority of women Veterans do not receive care in VHA. 

3 

Women Veterans Sourcebook Vol. 1: Introduction 

5 

Introduction
 

Background
 

Despite the fact that women have served in every United States military conflict since the American Revolution, 

they were not recognized as Veterans at the time that President Abraham Lincoln created the Veterans 

Administration (VA) “to care for him who shall have borne the battle, and for his widow, and his orphan.” 

When the congressional Government Accountability Office (GAO) released its first comprehensive report on 

Veterans Health Administration (VHA) care for women Veterans in 1982, women represented an extreme 

numeric minority group within an organization originally designed to meet the health care needs of men. 

Reports by the GAO and the VA Office of Inspector General in the late 1980s and early 1990s documented 

quality gaps in VHA women’s health care delivery. 

By the mid-1990s, major change had begun. Over the past two decades, VHA 

has rolled out numerous initiatives designed to improve access and quality of 

care for women Veterans. Among these were Comprehensive Women Veterans 

Health Centers, Continuing Medical Education offerings in women’s health, 

post-doctoral Fellowship training programs in women’s health, the Women’s 

Health Sciences Division of the National Center for Post Traumatic Stress 

Disorder (PTSD), women’s mental health specialty programs, a national 

Military Sexual Trauma Support team, and active solicitation of women’s 

health services research projects. 

Building on these earlier achievements, in late 2008, the VHA Women 

Veterans Health Strategic Health Care Group (WVHSHG) in VA Central 

Office launched a 5-year plan to redesign the women’s health care delivery system in VHA nationally. A fundamental component of this new vision was assuring that women Veterans receive comprehensive primary care from 

providers skilled in women’s health care. Every VHA health care system in the country now has a full-time Women 

Veterans Program Manager tasked with advocating for the health care needs of women using that facility. Miniresidencies in women’s health have been disseminated systemwide to enhance clinician competencies in women’s 

health. The WVHSHG oversees these efforts nationally. 

As part of this dynamic systems redesign, the WVHSHG identified the need for data to inform policy and program planning. While highly informative data on women Veterans are available from the research literature6

 and 

from various VHA reports (e.g., VHA Office of Policy and Planning, and the searchable VSSC Data Cube), the 

WVHSHG identified the need for detailed data specifically tailored to its strategic planning objectives and available to be queried in a timely way as issues emerge in VHA women’s health care delivery. 

Goldzweig CL, Balekian TM, Rolon C, Yano EM, Shekelle PG. The State of Women Veterans’ Health Research. Results of a Systematic 

Literature Review. J Gen Intern Med. 2006; 21(s3):S82-S92; Bean-Mayberry B, Batuman F, Huang C, Goldzweig CL, Washington DL, 

Yano EM, Miake-Lye I, Shekelle PG. Systematic Review of Women Veterans Health Research 2004–2008. VA-ESP Project #05-226; 2010. 

http://www.hsrd.research.va.gov/publications/esp/womens-health.pdf. 

6 
Women Veterans Sourcebook Vol. 1: Introduction 

6 

To address this need, the WVHSHG approached women’s health investigators with expertise in large database 

research at the Center for Health Care Evaluation, a VA Health Services Research & Development (HSR&D) 

Center of Excellence, and the Health Economics Resource Center at VA Palo Alto Health Care System. The resulting 

partnership was called the Women’s Health Evaluation Initiative, or WHEI. Since 2009, WHEI has been conducting analyses in response to queries by the WVHSHG. The analyses that WHEI produces are relevant to groups 

besides the WVHSHG, including policymakers, clinicians, researchers, advocates, and women Veterans. To facilitate 

dissemination of major findings to a broader audience, key sociodemographic and VHA health care utilization data 

have been organized in this Sourcebook. This document is the first volume; subsequent volumes of the Sourcebook 

are being developed to describe additional characteristics of women Veteran VHA patients and their health care. 

Methods 

Overview. This report presents the number, age, and service-connected disability status of women Veterans who 


received medical care in the Veterans Health Administration (VHA) (Part 1), along with information about their 


utilization of outpatient and inpatient VHA services (Part 2). Data for this report were derived from centralized 


VHA administrative files (the ADUSH Monthly Enrollment File, the SE Outpatient Encounter File, and the PTF 


Inpatient File, described in the Technical Appendix) spanning a 10-year period from Fiscal Year 2000 through Fiscal Year 2009 (FY00–FY09). Non-Veterans who use VHA services are not included in this report.
 

Characteristics examined. Sociodemographic characteristics examined in this report are age and service-connected 


disability status. Note that race/ethnicity data are not included among the sociodemographic characteristics due to 


data quality concerns about the race/ethnicity variable.7

 This report examines several specific types of outpatient 


utilization: total outpatient utilization, outpatient face-to-face visits with a clinician (i.e., excluding laboratory, 


radiology, and telephone encounters), primary care visits (total primary care visits as well as visits to primary care 


clinics and women’s health clinics, defined in Part 2), women’s specialty care, and mental health care. This report 


also quantifies the number of women with at least one inpatient stay. (See Technical Appendix for details of the 


algorithms used to create these variables and the data validity checks completed.)
 

Analyses. All data in this report are descriptive. 


The analyses in the sociodemographics section are organized as follows:
 

•	 Number of women Veteran VHA patients 

•	 Age distribution 

•	 Service-connected disability status 

The analyses in the utilization section are organized as follows: 

•	 Utilization of VHA services by women Veterans in FY09
 

− Overall [by type of care: total outpatient care, face-to-face outpatient care, primary care, women’s 


specialty care8

, mental health care] 

− Within key sub-populations (i.e., by age group and service-connected disability status) [by type of care] 

− Compared to utilization by men Veteran VHA patients [by type of care] 

•	 Longitudinal trends in the utilization of VHA services by women Veterans, FY00–FY09 [by type of care] 

7	 The VA Information Resource Center is currently working to identify optimal approaches to identification of race/ethnicity from VHA 

data sources. It is anticipated that race/ethnicity information will become available in a future volume of the Sourcebook. More information about race/ethnicity data quality and availability in VHA is provided at http://www.virec.research.va.gov/DataSourcesCategory/ 

DataQuality/Race.htm. Further observations on how race/ethnicity information in VHA data sources can be improved by linking to 

Medicare and Department of Defense sources can be found in this study: Stroupe K, Tarlov E, Zhang Q, Haywood T, Owens A, 

Hynes D. Utility of Medicare and DoD data for improving VA race data quality. Journal of Rehabilitation Research & Development. 

2010 Nov;47(8):781-96. http://www.rehab.research.va.gov/jour/10/478/Stroupe.html 

8 This category is separated into two parts: Gynecology and Women’s Surgery Clinic. 
Fig 1 Fig 2

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009 

Figure 1. Number of women Veteran VHA patients in each Figure 2. Number of men Veteran VHA patients in each year, 

year, FY00–FY09 FY00–FY09 

0 

100,000 

200,000 

300,000 

# WV VHA Patients 

0 

1,000,000 

2,000,000 

3,000,000 

4,000,000 

5,000,000 

# MV VHA Patients 

Key: VHA—Veterans Health Administration; WV—Women Veterans; MV–Men Veterans; FY—Fiscal Year 

Notes: Findings portray Veterans who use services at VHA facilities, not the entire Veteran population. See Technical Appendix for an 

explanation of how women Veterans were identified. 

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

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

Women Veterans Sourcebook Vol. 1: Sociodemographics 

Part 1: Sociodemographics 


Women Veteran VHA Patient Cohort Size 

Growth in number of women Veterans using VHA, FY00–FY09. While women Veterans remain a numerical minority group in VHA, the number using VHA services has nearly doubled in the past decade, growing from 159,630 

to 292,921—an 83% increase—between FY00 and FY09 (Figure 1). In contrast, the number of men Veterans 

in VHA has grown more slowly, from 3,225,712 to 4,846,869—a 50% increase (Figure 2). The 292,921 women 

Veterans who used any care at a VHA facility in FY09 represent about 6% of all Veterans using VHA in that year. 

Since 2004, the annual percent increase in the number of women Veteran VHA patients has been consistently 

four percentage points higher than the same percent increase for men Veterans. 

Notes to interpretation: These data reflect the VHA system at a national level. Specific geographic regions or individual VHA facilities may have experienced greater or lesser increases in the women Veteran patient population. 

Implications The number of women Veterans using VHA 

services has nearly doubled in the past decade. If growth continues 

at this pace, and especially if market penetration increases among 

the large group of women Veterans who currently do not use VHA, 

increasing demands upon VHA delivery systems for women are 

anticipated. 

7 
Women Veterans Sourcebook Vol. 1: Sociodemographics 

8 

Fig 3

Fig 4

 

 

Figure 3. Age distribution among women Veteran VHA patients, FY09 

44% 

14% 

42% 

Key: VHA—Veterans Health Administration; WV—Women 

Veterans; FY—Fiscal Year 

Notes: Findings portray age mix among Veterans who use VHA 

Age (Years) services and are not necessarily representative of the 

age mix of Veterans who do not use VHA. See Technical 65–110 Appendix for an explanation of how women Veterans 

were identified in data and how age was calculated, 45–64 

and for information on missing age values. 

18–44 Cohort: Women Veteran VHA users who have non-missing 

ages between 18 and 110 years old (inclusive) in year. 

N=159.548 in FY00, N=292,878 in FY09. 

Source: 	 WHEI analysis of ADUSH Monthly Enrollment File, FY09. 

 

Figure 4. Age distribution of women Veteran VHA patients (#), FY00 and FY09 

Key:	 VHA—Veterans Health Administration; FY—Fiscal Year; 

WV—Women Veterans 

# WV VHA Patients 

10,000 

FY00 

FY09 

Notes: Findings portray age mix among Veterans who use VHA 

services and are not necessarily representative of the 

8,000 age mix of Veterans who do not use VHA. See Technical 

Appendix for an explanation of how women Veterans 

6,000 were identified in data and how age was calculated, 

and for information on missing age values. 4,000 Cohort:	 Women Veteran VHA users who have non-missing 

ages between 18 and 100 years old (inclusive) in year. 2,000 N=159,548 in FY00, N=292,878 in FY09. 

Source: WHEI analysis of ADUSH Monthly Enrollment Files, 0 

20 40 60 80 100 FY00–FY09.
 

Age (Years) 


 

Ages of Women Veteran VHA Patients 

Age mix, FY09. Women Veteran VHA patients cross the full adult lifespan, from late teen years to older than 100 

years. The history of U.S. military conflicts influences their age distribution; while some women join the military 

in times of peace, large boluses of women join at the time of major military conflicts. Many of those who join the 

military are in their late teens or early 20s. Thus, the age distribution of women in part reflects war era cohort 

effects. 

In FY09, the majority of women Veterans in VHA were less than 65 years old, with approximately equal numbers 

in the 18–44 (42%) and the 45–64 (44%) age groups (Figure 3). Substantial numbers of women were at the age 

extremes: 5% were younger than 25, and 4% were older than 85. 

Changes in age distribution, FY00–FY09. Figure 4 shows the number of women at each age in FY00 (dotted line), 

and again in FY09 (bold line). In FY00, the distribution had two main peaks: The tallest peak had a maximum 

at age 44, and the second peak had a maximum at age 76. By FY09, the peaks had shifted forward. The peak that 

had been tallest in FY00 was even taller and had its maximum at age 47. The second FY09 peak had its maximum 

at age 85; notably, the number of women in this age cohort did not shrink significantly between FY00 and FY09, 

despite the potential for attrition (e.g., due to death or transfer to non-VHA long-term care facilities). This suggests that older women have joined VHA at a pace commensurate with their attrition. Furthermore, by FY09 a 

substantial new third peak had appeared, with its maximum at age 27. 
Fig 5

Fig 6

 

 

 

 

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009 

Figure 5. Age distribution of women Veteran VHA patients (%), FY00–FY09 

Key:	 VHA—Veterans Health Administration; FY—Fiscal Year; 

WV—Women Veterans 

% WV VHA Patients

51% 

19% 

42% 

14% 

20 

0 

40 

60 

80 

100 

Age (Years) 

30% 44% 

Notes: Findings portray age mix among Veterans who use VHA 

services and are not necessarily representative of the 

65–110 

age mix of Veterans who do not use VHA. See Technical 

Appendix for an explanation of how women Veterans 

were identified in data and how age was calculated, and 

45–64 for information on missing age values. 

Cohort: Women Veteran VHA users who have non-missing 

18–44 ages between 18 and 110 years old (inclusive) in year. 

N=292,894 in FY09.
 

Source: WHEI analysis of ADUSH Monthly Enrollment Files, 


FY00–FY09. 

 

 

 

Figure 6. Age group of Veteran patients, by gender, FY09 

Age (Years) Key: VHA—Veterans Health Administration; FY—Fiscal Year 

100 85–110 Notes:	 Findings portray age mix among Veterans who use 

VHA services; they are not necessarily representative 75–84 80 of Veterans who do not use VHA care. See Technical 

% VHA Patients

65–74 	 Appendix for an explanation of how Veterans were 

60 identified in data and how age was calculated, and for 55–64 

information on missing age values.

45–54 40 Cohort: Women and men Veteran VHA users who have non35–44 missing ages between 18 and 110 years old (inclusive) 

20 in FY09. Women: N=292,894; Men: N=4,846,792. 25–34 Source:	 WHEI analysis of ADUSH Monthly Enrollment Files, 

0 18–24 FY09.

Women Men 

Women Veterans Sourcebook Vol. 1: Sociodemographics 

Even though the total number of women under age 45 increased from 81,745 in FY00 to 123,797 in FY09, the 

proportion of women under age 45 actually decreased, from 51% in FY00 to 42% in FY09 (Figure 5). This is 

because the total number of women using VHA increased rapidly over this period. Similarly, although the number 

of 18–34 year olds also increased over the decade (from 36,354 in FY00 to 67,219 in FY09), this age group did 

not increase as a proportion of the total women Veteran patient population: 18–34 year olds comprised 23% of the 

population in FY00 and 23% of the population in FY09. 

Over this same period, the 45–64 year old cohort became much larger, both numerically (47,320 in FY00, 

128,178 in FY09) and as a proportion of all women patients (30% in FY00, 44% in FY09) (Figure 5). 

Changes in age distribution, FY00–FY09 (continued). Compared with the numbers of women in the 18–44 and 

45–64 age groups, relatively fewer women were 65–110 years old. Between FY00 and FY09, the number of women in this age cohort grew from 30,488 to 40,919, but this group decreased as a proportion of all women Veteran 

VHA patients, from 19% to 14% (Figure 5). 

Women compared to men, FY09. Figure 6 indicates that, compared to men Veteran VHA patients in FY09, the 

population of women is substantially younger: 86% of women compared to 54% of men are less than 65 years 

old, and 42% of women compared to 12% of men are less than 45 years old. 

9 
Fig 7

 

 

 

 

Figure 7. Service-connected disability status among women Veteran VHA patients, FY00 and FY09 # WV VHA Patients 

300,000 

200,000 

100,000 

0 

4% 

2000 2009 

52% 

45% 

30% 

21% 

12% 

32% 

5% 

Key:	 VHA—Veterans Health Administration; FY—Fiscal Year; Service-Connected WV—Women Veterans; SC—Service-connected Disability Rating Notes:	 Findings portray SC status mix among Veterans who use (Percent) VHA services, who are not necessarily representative of 

No SC Veterans who do not use VHA. See Technical Appendix 

for an explanation of how women Veterans were 

SC: 0–49 identified in data and how SC status was determined, 

and for information on missing SC values. SC: 50–99 Cohort:	 Women Veteran VHA users with non-missing SC values 

in year. N=158,160 in FY00, N=292,108 in FY09. SC: 100 

Source:	 WHEI analysis of ADUSH Monthly Enrollment Files, 

FY00 and FY09. 

Women Veterans Sourcebook Vol. 1: Sociodemographics 

Implications The number of young women in VHA has been growing rapidly in 

recent years. This rapid demographic shift highlights the need to assure ample capacity 

for clinical services necessary for women in their reproductive years and to assure that 

health care providers’ knowledge and skills are up to date in this clinical domain. 

The tallest peak in the age distribution of women Veteran patients was at age 47 

in FY09. Twenty years from now, this large group of women will be nearing their 

seventies. These women could require more intensive health care services as they age, 

including geriatric and extended care services and, where applicable, support for their 

role as caregivers. Also, as these women become Medicare-eligible, coordination of 

care across systems may become increasingly important. 

Service-Connected Disability Status 

of Women Veteran VHA Patients 

Service-connected status indicates an injury or illness that was incurred or aggravated while serving in the armed 

forces. The Veterans Benefits Administration (VBA) reviews disability compensation claims using a multi-step 

process. VBA first determines whether the disability was incurred or aggravated during active military service—if 

so, the Veteran receives “service connected” (SC) disability status. The Veteran’s SC disability is then assessed and 

rated for severity from 0 to 100 percent.9

 Finally, VBA calculates disability compensation benefits based on the SC 

disability rating as well as other factors, such as dependents. 

Service-connected status, FY09. More than half (55%) of women Veteran VHA patients in FY09 had an SC 

disability rating (Figure 7). 

Among all women Veterans using VHA in FY09, 14,309 (5%) had an SC disability rating of 100 percent. About 

a quarter of women (26%, or 75,272 women) had an SC disability rating of 50 percent or higher. 

Changes in proportion of women with service-connected disability status over time, FY00 vs. FY09. Also seen 

in Figure 7, the proportion of women Veteran VHA patients with any SC disability rating had increased, from 

48% in FY00 to 55% in FY09 (representing a numeric increase from 76,377 women to 161,543 women). The 

To enhance the clarity and readability of this report, an editorial decision has been made to spell “percent” in reference to service-connected disability ratings, e.g. “SC disability rating of 70 percent.” In all other measures of percentage, the percent symbol (%) is used. 

10 

9 
Women Veterans Sourcebook Vol. 1: Sociodemographics 

11 

Fig 8 Fig 9

 

 

 

 

 

 

 

 

Figure 8. Service-connected disability status among women Figure 9. Service-connected disability status among Veteran 

Veteran VHA patients, by age, FY09 VHA patients, by gender, FY09 

100 100

Service-Connected Service-Connected

80 Disability Rating 80 Disability Rating

Women Men

Age 18–44 Age 45–64 Age 65–110 

% WV VHA Patients 

(Percent) (Percent)

60 

% VHA Patients

No SC 60 No SC

40 SC: 0–49 SC: 0–49 

SC: 50–99 

40 

SC: 50–99 20 20 

SC: 100 SC: 100 

0 

0 

Key:	 VHA—Veterans Health Administration; FY—Fiscal Year; Key: VHA—Veterans Health Administration; FY—Fiscal Year; 

WV—Women Veterans; SC—Service-connected SC—Service-connected 

Notes:	 Findings portray SC and age status among Veterans who Notes: Findings portray SC status among Veterans who use 

use VHA services, who are not necessarily representative VHA services, who are not necessarily representative of 

of Veterans who do not use VHA. See Technical Appendix Veterans who do not use VHA. See Technical Appendix for 

for an explanation of how women Veterans were identified an explanation of how Veterans were identified in data 

in data and how age and SC status were calculated, and for and how SC status was calculated, and for information on 

information on missing age and SC values. missing SC values. 

Cohort:	 Women Veteran VHA users who have non-missing ages Cohort: Women and men Veteran VHA users with non-missing SC 

between 18 and 110 years old (inclusive) in FY09 and who values in FY09. Women: N=292,108; Men: N=4,838,232. 

also have non-missing SC values. N=292,081. Source: WHEI analysis of ADUSH Monthly Enrollment File, FY09. 

Source:	 WHEI analysis of ADUSH Monthly Enrollment File, FY09. 

proportion of women Veterans with SC disability ratings of 50 percent or higher increased over this 10-year 

period as well: Those with ratings of 50–99 percent increased from 12% to 21%, and those with a rating of 100 

percent increased from 4% to 5%. 

Service-connected disability status by age, FY09. Figure 8 shows that 68% of women Veteran VHA patients who 

are 18–44 years old had an SC disability rating, compared with 55% of those who are 45–64 years old and 19% 

of those who are 65–110 years old. More women Veteran VHA patients in the 45–64 age group had an SC disability rating of 100 percent (7%) than in the other age groups (4% of 18–44 years; 3% of 65–110 years). 

Women compared to men, FY09. A higher proportion of women Veteran VHA patients than men had SC disability ratings (Figure 9). Fifty-five percent of women Veterans had any SC disability rating, compared with 41% 

of men. Among these Veteran VHA patients, 26% of women and 19% of men had an SC disability rating higher 

than 50 percent. 

Notes to interpretation: First, SC disability status can result from a variety of exposures including, but not limited 

to, combat. The administrative data used for this report do not indicate the diagnoses associated with an individual’s 

SC disability rating. Second, these data show the proportion of women and men VHA patients who carry SC 

disability status. These data do not show the total number of Veterans nationally who carry SC disability status: 

Veterans who do not use VHA care are not included in the cohort examined here. Therefore, no conclusions can 

be drawn about what proportion of all women and men Veterans in the U.S. population carry an SC disability 

status. Third, these data only identify Veterans who have been formally granted SC disability status; VHA patients 

who have a military service-related illness or disability, but who have not applied for SC disability status, are not 

identified in these data as having an SC disability rating. Higher proportions of VHA patients with SC disability 
Women Veterans Sourcebook Vol. 1: Sociodemographics 

status in one group compared to another group (e.g., women versus men) could 

imply either that the proportion of Veterans in that group applying for and 

being granted SC disability status is greater, or that Veterans in that group who 

have SC disability status are more likely to be using VHA services. Similarly, 

higher proportions of VHA patients in one group compared to another group 

carrying higher SC disability ratings could imply either that the proportion of 

Veterans in that group applying for and being granted higher SC disability 

ratings is greater, or that Veterans in that group who have higher SC disability 

ratings are more likely to be using VHA services. Finally, Veterans who have 

only recently applied for SC disability status will appear in the database as 

“non-SC” until the time, if any, that they are granted SC disability status and 

VHA is updated regarding this change. 

Implications The proportion of women Veteran VHA patients with a 

service-connected disability rating, as well as the proportion with SC disability 

ratings of 50 percent or more, has increased over the decade. More than half 

of women Veterans in VHA now carry an SC disability rating, some of whom 

are very young. These women will be eligible for lifelong VHA care for their 

service-connected conditions. 

12 
Women Veterans Sourcebook Vol. 1: Utilization 

13 

 

 

 

Figure 10. Proportion of women Veteran VHA patients by frequency of face-to-face outpatient visits, FY09 

37% 17% 

13% 

5% 

29% 

Number Key: VHA—Veterans Health Administration; FY—Fiscal Year 

of Visits Notes: Multiple face-to-face visits with different clinic stop 

codes can occur on the same day. See Technical Appendix 0 for an explanation of how women Veterans were 

identified in data. Percentages do not sum to 100% due 1 to rounding. 

Cohort: Women Veteran VHA users in FY09. N=292,921. 2–6 

Sources: WHEI analysis of ADUSH Monthly Enrollment File, FY09; 

VA Outpatient Utilization File (SE), FY09. 7–11 

12+ 

Fig 10

Part 2: Utilization of VHA Care 


Women Veterans’ Utilization in FY09 

Outpatient Care 

Definition of terms used. When describing all outpatient care combined, Total Outpatient Care refers to any type 

of outpatient care (i.e., all clinic types and all other encounter types appearing in the SE Outpatient Encounter 

File are considered outpatient care). In contrast, Face-to-Face Outpatient Care represents face-to-face care with a 

clinician (such as primary care visits, mental health visits, specialty care visits, rehabilitation care visits, etc.). Other 

types of encounters that do not involve a face-to-face visit with a clinician (such as lab tests, radiology tests, and 

telephone encounters) are not included in face-to-face care. Outpatient care may occur at a major VHA facility or 

at a VHA community-based outpatient clinic. 

Total Outpatient Care. Among the 292,921 women Veterans who used any VHA care in FY09, about 98% 

(287,447) had at least one outpatient encounter of any kind in FY09. This indicates that only a very small proportion of women used inpatient care, fee-basis care, contract care, or pharmacy services as their exclusive type of 

VHA care in FY09.10, 11 Among women who had any outpatient encounters in FY09, VHA provided, on average, 

19 outpatient encounters per woman. 

Face-to-Face Outpatient Care. Among all women Veterans who used any VHA care in FY09, about 95% had at 

least one outpatient encounter that involved a face-to-face visit12 with a health care provider (Figure 10). A small 

group of women Veterans (13%) had only one visit in the outpatient setting. About 83% of women Veteran VHA 

10	 Fee-basis care and contract care are services provided by non-VHA providers but paid for through VHA. 

11	 In FY09, approximately 0.1% of women Veteran VHA patients had inpatient care but no VHA-based outpatient care; about 0.8% had 

fee-basis outpatient care but no VHA-based inpatient or outpatient care; and 1.0% had neither VHA-basis inpatient/outpatient care 

nor fee-basis outpatient care (and likely had prescription care, contract care, or fee-basis inpatient care only). 

12	 Henceforth in this report, the term “visit” refers to an encounter with a clinician. For the purposes of this report, more than one visit 

can occur on a single day. 
Women Veterans Sourcebook Vol. 1: Utilization 

14 

Fig 11

Fig 12

 

 

 

 

 

Figure 11. Proportion of women and men Veteran VHA patients Figure 12. Proportion of women and men Veteran VHA patients 

by frequency of face-to-face outpatient visits, FY09 by frequency of face-to-face outpatient visits, by 

age group, FY09 

Women Men 

% VHA Outpatients 

0 

20 

40 

60 

80 

100 

0 

1 

2–6 

7+ 

Number 

of Visits 

0 

20 

40 

60 

80 

100 

% VHA Outpatients

0 

1 

2–6 

7+ 

Number 

of Visits 

Age 18–44 Age 45–64 Age 65–110 Women Men Women Men Women Men 

Key: VHA—Veterans Health Administration; FY—Fiscal Year Key: VHA—Veterans Health Administration; FY—Fiscal Year 

Notes: Multiple face-to-face visits with different clinic stop codes Notes: Multiple face-to-face visits with different clinic stop codes 

can occur on the same day. See Technical Appendix for an can occur on the same day. See Technical Appendix for an 

explanation of how Veterans were identified in data. explanation of how Veterans were identified in data, and for 

Cohort: Women and men Veteran VHA users in FY09. Women: information on missing age values. 

N=292,921; Men: N=4,846,869. Cohort: Women and men Veteran VHA users who have non-missing 

Sources: WHEI analysis of ADUSH Monthly Enrollment File, FY09; ages between 18 and 110 years old (inclusive) in FY09. 

VA outpatient utilization file (SE), FY09. Women: N=292,894; Men: N=4,846,792. 

Sources: WHEI analysis of ADUSH Monthly Enrollment File, FY09; 

VA outpatient utilization file (SE), FY09. 

patients had at least two face-to-face visits. A substantial number of women Veteran VHA patients used VHA care 

heavily in FY09: 29% made more than 12 visits. Among Veterans who had any face-to-face outpatient visits in 

FY09, VHA provided, on average, 11.9 face-to-face outpatient visits per woman. 

Figure 11 compares women Veterans’ utilization of face-to-face outpatient services to that of men Veterans, for 

FY09. Among Veteran VHA patients, a greater proportion of women than men had more than six face-to-face 

visits (46% vs. 40%) as well as 12+ face-to-face visits in FY09 (29% vs. 24%). 

Use of any face-to-face care by women Veteran outpatients in FY09 varied little by age group: 95% of 18–44 year 

olds, 96% of 45–64 year olds, and 94% of 65–110 year olds used face-to-face care. The highest intensity of utilization was seen in the 45–64 year old age group: Among them, 53% had more than six face-to-face visits in FY09, 

compared with 42% of 18–44 year olds and 37% of 65–110 year olds (Figure 12). 

Figure 12 also shows that within each age group, about the same proportion of women and men Veterans used 

face-to-face care at least once in FY09. However, heavier levels of utilization were more common in women than 

in men, especially below age 65: Among 18–44 year old Veterans, 42% of women vs. 35% of men had more than 

six face-to-face outpatient visits in the year; among 45–64 year olds, 53% (women) vs. 48% (men) had more than 

six visits; and among 65–110 year olds, 37% (women) vs. 34% (men) had more than six visits. 

Notes to interpretation: In all cases, outpatient utilization described in Part 2 does not include “fee-basis” care. 

While both women and men may receive fee-basis services, some facilities may rely heavily on fee-basis care for 

some gender-specific women’s health services that are not available onsite. Therefore, this issue has the potential to 

be of particular relevance to women. In fact, exploratory analyses indicate that a greater proportion of women than 
Women Veterans Sourcebook Vol. 1: Utilization 

15 

men received fee-basis services in FY09.13 This preliminary finding raises the possibility that the gender differences 

described above (that is, that women tended to use more care than men) would be even more pronounced if feebasis care were added to the VHA outpatient care presented here. 

Outpatient utilization in Part 2 also does not include use of contract care or pharmacy services. 

It is important to recognize that some women and men Veterans split their care between VHA and non-VHA 

providers (e.g., Medicare, Medicaid, private insurance, or self-pay). The frequency of visits presented in this report 

represents VHA care only, and may underestimate the total care women Veteran VHA patients receive from all 

health care sources combined. 

When interpreting gender differences, it is important to recognize that these analyses present raw results, without 

adjustment for patient characteristics such as number of medical conditions, which can influence conclusions 

about gender differences in use of VHA services.14 

Primary Care 

Definition of terms. This report uses the term Total Primary Care 

to refer to care received in either of the following two settings in 

which women may receive VHA primary care services: 

•	 Primary Care Clinic (PC) refers to primary care provided 


in a general medical clinic (although sometimes it refers 


to care provided in a women’s health clinic as well). Such 


clinics provide preventive care and care for a wide range 


of gender-neutral conditions (such as diabetes or upper 


respiratory tract infections). Such clinics may additionally 


provide gender-specific care to women (such as cervical 


cancer screening and breast exams), or may refer women to 


a different clinic for such gender-specific services. 


•	 Women’s Health Clinic (WHC) refers to primary care services provided in a clinic designed specifically for 

women. Such clinics sometimes provide comprehensive primary care services to women (i.e., preventive 

health care for gender-neutral conditions, and care for gender-specific conditions), and sometimes provide 

care only for gender-specific conditions (such as cervical cancer screening and breast exams for women who 

get most of their primary care in a general medical clinic). Note: There is substantial variability in how different VHA facilities code primary care for women. Prior work has quantified this variability by examining 

the percent of women at a facility who had at least one WHC visit (stop code 322). Some facilities known to 

have WHCs had no patients with 322 coded, suggesting variability in how the code was used and interpreted.15 This is consistent with the fact that, since 2005, a number of facilities are known to have started coding 

primary care received in WHCs with codes that fall under the PC definition used in this report. This leads 

to an important caveat about WHC data in this report: While estimates of “Total Primary Care” (the sum of 

PC and WHC) are reliable, the proportion of that care occurring in WHCs cannot be estimated with confidence 

at present. Planned changes in coding procedures for WHC are expected to improve the interpretability of 

future data for this specific type of care. 

13 34% of women Veteran VHA patients had at least one record in VHA’s FY09 outpatient fee-basis files, compared to 16% of men. 

14 Frayne SM, Yu W, Yano EM, et al., Gender and use of care: planning for tomorrow’s Veterans Health Administration. J Women’s Health. 

Oct 2007;16(8):1188-1199. 

15 Herrera L, Iqbal S, Hayes PM, Phibbs CS, Friedman SA, Laungani L, Berg E, Frayne SM. Can Stop Codes Identify Women’s Health Care? 

Poster Presentation at VA HSR&D Women’s Health Services Research Conference in Washington D.C., July, 2010. 
Women Veterans Sourcebook Vol. 1: Utilization 

16 

Fig 13

Fig 14

 

 

 

Figure 13. Proportion of women and men Veteran VHA outpatients by frequency of total primary care visits, FY09 

100 Number Key: VHA—Veterans Health Administration; FY—Fiscal Year 

of Visits Notes: Total primary care stop codes include 170, 171, 210, 301, 

80 0 310, 319, 323, 348, 350, 394, 322, and 704. See Technical 

Women Men 

Appendix for descriptive stop code names, and for an

% VHA Outpatients

60 

40 

20 

0 

explanation of how Veterans were identified in data. 1 

Cohort: Women and men Veteran VHA outpatients in FY09. 

2 Women: N=287,447; Men: N=4,747,050. 

Sources: WHEI analysis of ADUSH Monthly Enrollment File, FY09; 

3–5 VA outpatient utilization file (SE), FY09. 

6+ 

 

 

 

Figure 14. Proportion of women and men Veteran VHA outpatients by frequency of total primary care visits, by age group, FY09 

100 Key: VHA—Veterans Health Administration; FY—Fiscal Year 

Number Notes: Total primary care stop codes include: 170, 171, 210, 80 of Visits

% VHA Outpatients

301, 310, 319, 323, 348, 350, 394, 322, and 704. See 

0 Technical Appendix for descriptive stop code names, for 60 

an explanation of how Veterans were identified in data, 

1 and for information on missing age values. 

Cohort: Women and men Veteran VHA outpatients who have non40 

20 2 	 missing ages between 18 and 110 years old (inclusive) in 

FY09. Women: N=287,436; Men: N=4,747,995. 3+ 0 Women Men Women Men Women
 Men
 

Age 18–44 Age 45–64 Age 65–110 

Sources: WHEI analysis of ADUSH Monthly Enrollment File, FY09; 

VA outpatient utilization file (SE), FY09 outpatient 

utilization file (SE), FY09. 

Total Primary Care (PC and WHC combined). Among women Veterans who used VHA outpatient care in FY09, 

90% have been seen by a VHA primary care provider in a PC setting and/or in a WHC setting (see the Technical Appendix, Section 4, for clinic code specifications). Regarding Total Primary Care, in FY09, 23% of women 

Veterans had exactly one primary care visit in VHA, 57% had 2–6 primary care visits, and 10% had more than six 

primary care visits. Among women Veterans who used any VHA primary care in FY09 (PC and WHC combined), 

the average number of visits to any primary care clinic was 3.5 visits per woman. 

Figure 13 compares women Veterans’ utilization of total primary care services to that of men Veterans for FY09. 

Among both women and men Veteran VHA outpatients, about 90% had any primary care visits in FY09. Among 

Veteran primary care patients, a greater proportion of women than men had at least three primary care visits in FY09 

(47% vs. 42%), and a greater proportion of women than men had at least six primary care visits (15% vs. 11%). 

Figure 14 demonstrates that, among women Veterans, primary care use (PC and WHC combined) varies by age 

group. Regular use was most common in the middle age group: Among women in the 45–64 age group, 72% had 

two or more total primary care visits in FY09, compared with 61% of 18–44 year olds and 67% of 65–110 year olds. 

Figure 14 also compares women to men. Within each age group, more women Veterans than men Veterans were 

regular users of primary care (i.e., having at least two primary care visits in FY09), with the difference being most 

pronounced in the 18–44 year old age group (61% vs. 50%), but still marginally present among 45–64 year olds 

(72% vs. 70%) and 65–110 year olds (67% vs. 65%). Similarly, within each age group more women than men 

were frequent users of primary care (i.e., at least three visits in FY09); this was seen among 18–44 year olds (42% 

vs. 29%), 45–64 year olds (53% vs. 47%), and in 65–110 year olds (46% vs. 40%). 
Fig 15

 

 

 

Figure 15. Proportion of women and men Veteran VHA outpatients by frequency of total primary care visits, by service-


connected disability ratings, FY09
 

Key:	 VHA—Veterans Health Administration; FY—Fiscal Year; 

SC—Service-connected 

0 

20 

40 

60 

80 

100 

NO SC SC: 0–49 SC: 50–99 SC: 100 

% VHA Outpatients 

Number 

of Visits

 Women 

Men

 Women 

Men

 Women 

Men

 Women 

Men 

0 Notes: Total primary care stop codes include: 170, 171, 210, 

301, 310, 319, 323, 348, 350, 394, 322, and 704. See 

Technical Appendix for descriptive stop code names, for 1 

an explanation of how Veterans were identified in data, 

2 and for information on missing SC values. 

Cohort: Women and men Veteran VHA outpatients with non3+ missing SC values in FY09. Women: N=286,653; Men: 

N=4,739,888. 

Sources: WHEI analysis of ADUSH Monthly Enrollment File, FY09; 

VA outpatient utilization file (SE), FY09. 

SC Disability Rating (Percent) 

Women Veterans Sourcebook Vol. 1: Utilization 

Figure 15 examines associations between primary care use, service-connected (SC) disability status, and gender. 

Focusing first on the women Veterans shown in this figure, those with SC disability ratings of 50 percent or 

higher tended to be regular primary care users (at least two primary care visits in FY09) or frequent primary care 

users (at least three primary care visits in FY09). Eighty-eight percent of women Veteran outpatients identified as 

not having an SC disability rating used any primary care services in FY09, compared with women Veterans with 

SC disability ratings of 0–49 percent (89%), 50–99 percent (93%), and 100 percent (91%). Forty-four percent 

of women Veteran outpatients identified as not having an SC disability rating visited primary care clinics three 

or more times in FY09, compared to women with SC disability ratings of 0–49 percent (44%), 50–99 percent 

(57%), and 100 percent (61%). 

Figure 15 also compares women to men. Within most SC disability rating categories (0–49 percent, 50–99 percent, 

and 100 percent), the proportion of women and men Veteran VHA outpatients who used one or more VHA primary care services in FY09 is similar. The exception is that, within the group of Veterans identified as not having 

an SC disability rating, a slightly lower proportion of women than men used primary care services in FY09. Within every SC disability rating category, more women than men used primary care three or more times in FY09. 

Implications Women Veterans use VHA primary care services even more heavily than do men Veterans. 

 Clinicians with a large number of women in their panels may require adjustments in panel size or scheduling 

profiles to assure that women have sufficient access to care. 

Primary Care Clinic (PC). Figure 16 shows that more than 75% of women Veteran VHA patients received at least 

some of their primary care in a PC in FY09. Although 26% of women Veterans only visited a PC once in FY09, 

52% returned at least twice, and 34% returned at least three times. Among women Veterans who received primary 

care in a PC in FY09, the average number of PC visits was 3.0 per woman. 

Women’s Health Clinic (WHC). Figure 17 shows that, compared to use of PC clinics, fewer women received any of 

their primary care in WHCs: 37% of women Veteran VHA patients received at least some of their primary care 

services in FY09 in a WHC. (See Definition of Terms, page 15, for limitations of WHC data.) Among all women 

Veteran VHA outpatients, 20% had exactly one WHC visit. Among women Veterans who received any primary 

care in a WHC in FY09, the average number of WHC visits was 2.1 per woman. 

17 
Fig 16

Fig 17

Fig 18

Figure 16. Proportion of women Veteran VHA outpatients by Figure 17. Proportion of women Veteran VHA outpatients by 

frequency of primary care clinic (PC) visits, FY09 frequency of women’s health clinic (WHC) visits, FY09 

22% 

26% 

18% 

25% 

9% 

0 

6+ 

2 

1 

3–5 

Number 

of Visits 

63% 20% 

8% 

7% 

2% 

0 

6+ 

2 

1 

3–5 

Number 

of Visits 

Key:	 VHA—Veterans Health Administration; FY—Fiscal Year; PC—Primary Care Clinic; WHC—Women’s Health Clinic 

Notes:	 PC stop codes include 170, 171, 210, 301, 310, 319, 323, 348, 350 and 394. WHC stop codes include 322 and 704. Clinic 322 is 

“Women’s Clinic” and clinic 704 (used much less frequently) is “Pap Test Clinic.” See Technical Appendix for descriptive stop code 

names and for an explanation of how women Veterans were identified in data. 

Cohort: Women Veteran VHA outpatients in FY09. N=287,447. 


Sources: WHEI analysis of ADUSH Monthly Enrollment File, FY09; VA outpatient utilization file (SE), FY09.
 

 

 

 

 

 

Figure 18. Proportion of women Veteran VHA outpatients by which primary care clinics they use, FY09 

Key:	 VHA—Veterans Health Administration; FY—Fiscal 

Year; PC—Primary Care Clinic; WHC—Women’s Health 

Care Clinic 

Both PC and WHC Notes:	 PC stop codes include 170, 171, 210, 301, 310, 319, 

323, 348, 350, and 394. WHC stop codes include 322 and

WHC Only 704. Clinic 322 is “Women’s Clinic” and clinic 704 (used 

much less frequently) is “Pap Test Clinic.” See Technical 

PC Only Appendix for descriptive stop code names 

and an explanation of how women Veterans were 

No Primary Care identified in data. 

Cohort: Women Veteran VHA outpatients in FY09. N=287,447. 

Sources: WHEI analysis of ADUSH Monthly Enrollment File, 

FY09; VA outpatient utilization file (SE), FY09. 

53% 

11% 

26% 

10% 

Clinics Used 

 

Women Veterans Sourcebook Vol. 1: Utilization 

Notes to interpretation: The results for PC and WHC should be interpreted with substantial caution, due to variability in the ways different VHA facilities code primary health care for women (see Definition of Terms, page 15, 

for information about coding variability for women’s health care). For example, the fact that so many WHC 

users made only one visit to a WHC in FY09 may reflect the fact that, at some facilities, WHCs have historically been used (in part or in whole) to provide gender-specific services like Pap smears to women who receive the 

rest of their primary care in PCs. Likewise, the proportion of women using a WHC may actually be higher than 

reported here, because some facilities denote care received in WHC with the codes used under this 

PC definition. 

With these caveats in mind, in FY09, among women Veteran VHA patients, 53% received primary care in PC clinics 

only (and not in WHCs), 11% received primary care in WHCs only, 26% received primary care in both settings, 

and 10% received no primary care (Figure 18). 

18 
Fig 19. Proportion of women Veteran VHA outpatients by frequency of women’s primary care

Fig 20. Proportion of women Veteran VHA outpatients by frequency of mental health visits

 

 

Figure 19. Proportion of women Veteran VHA outpatients by frequency of women’s health clinic (WHC) visits, by age group, FY09 

100 Key: VHA—Veterans Health Administration; FY—Fiscal Year Number 

Notes: WHC stop codes include: 322 and 704. WHC stop codes of Visits
 

80 
 include 322 and 704. Clinic 322 is “Women’s Clinic” and 

0 clinic 704 (used much less frequently) is “Pap Test Clinic.” 

See Technical Appendix for an explanation of how women 60 1 Veterans were identified in data, for descriptive stop code 

names, and for information on missing age values. 40 2

Cohort: Women Veteran VHA outpatients who have non-missing 

3–5 ages between 18 and 110 years old (inclusive) in FY09. 20 N=287,436. 

6+ Sources: WHEI analysis of ADUSH Monthly Enrollment File, FY09; 0 VA outpatient utilization file (SE), FY09. Age 18–44 Age 45–64 Age 65–110 

% WV VHA Outpatients 

 

 

 

 

Figure 20. Proportion of women Veteran VHA outpatients by frequency of mental health visits, FY09 

Key: VHA—Veterans Health Administration; FY—Fiscal Year 

Notes: See Technical Appendix for an explanation of how 

women Veterans were identified in data and how mental 

0 health utilization was ascertained. 

Cohort: Women Veteran VHA outpatients in FY09. N=287,447. 1 Sources: WHEI analysis of ADUSH Monthly Enrollment File, FY09; 

VA outpatient utilization file (SE), FY09 2–6 

7–11 

12+ 

63% 

9% 

16% 

5% 

7% 

Number 

of Visits 

Women Veterans Sourcebook Vol. 1: Utilization 

The proportion of women Veterans receiving primary care in WHC clinics differs between those who are less than 

65 years old and those who are 65–110 years old (Figure 19). Among women Veteran outpatients who are either 

18–44 years old or 45–64 years old, about 39% had at least one primary care visit in a WHC in FY09. Among 

women Veterans who are 65–110 years old, only 23% attended a WHC in FY09. 

Specialty Care for Women 

In addition to women’s health clinics, VHA provides gender-specific care to women in two additional settings: 

gynecology clinic and women’s surgery. 

Gynecology Clinic (clinic stop code 404). In FY09, about 15% (41,896 women) of women Veteran outpatients 

attended gynecology clinic at least once, and 5% attended this clinic at least twice. Those women Veterans who 

did attend a gynecology clinic attended an average of 1.7 times during FY09. 

Women’s Surgery (clinic stop code 426). Far fewer (about 500) women Veterans obtained care in the women’s 

surgery clinic. Those who did attend women’s surgery attended an average of 1.5 times during FY09. 

Mental Health Care 

Among women Veteran VHA outpatients, 37% used any mental health service through VHA in FY09. For those 

who used mental health services, use tended to be moderate or heavy. Among women Veteran outpatients, 9% 

had one visit, 16% had 2–6 visits, 5% had 7–11 visits, and 7% had 12 or more visits (Figure 20). Those women 

Veterans who attended VHA mental health clinics in FY09 averaged 8.7 mental health visits during the year. 

19 
Fig 21. Proportion of women Veteran VHA outpatients by frequency of mental health visits

Fig 22. Proportion of women and men Veteran VHA outpatients by frequency of mental

 

 

Figure 21. Proportion of women and men Veteran VHA outpatients by frequency of mental health visits, FY09 

100 

Number Key: VHA—Veterans Health Administration; FY—Fiscal Year 

of Visits Notes: See Technical Appendix for an explanation of how 80 

Women Men 

Veterans were identified in data and how mental health 0 

utilization was ascertained. 

1 Cohort:	 Women and men Veteran VHA outpatients in FY09. 

Women: N=287,447; Men: N=4,748,050. 

2–6 Sources: WHEI analysis of ADUSH Monthly Enrollment File, FY09; 

VA outpatient utilization file (SE), FY09. 

7–11 

12+ 

% VHA Outpatients 60 

40 

20 

0 

 

 

 

Figure 22. Proportion of women and men Veteran VHA outpatients by frequency of mental health visits, by age group, FY09 

100 Number Key: VHA—Veterans Health Administration; FY—Fiscal Year 

of Visits Notes: See Technical Appendix for an explanation of how 80 

Age 18–44 Women MenAge 45–64 Women MenAge 65–110 Women Men 

% VHA Outpatients 

Veterans were identified in data and how mental health 0 utilization was ascertained, and for information on 60 

1 missing age values. 

40 Cohort:	 Women and men Veteran VHA outpatients who have nonmissing ages between 18 and 110 years old (inclusive) in 2–6 20 FY09. Women: N=287,436; Men: N=4,747,995. 

Sources: WHEI analysis of ADUSH Monthly Enrollment File, FY09; 7+ 0 VA outpatient utilization file (SE), FY09. 

Women Veterans Sourcebook Vol. 1: Utilization 

Figure 21 compares mental health utilization levels between women and men Veteran VHA patients in FY09. 

Overall, a higher proportion of women than men used any mental health services. Among Veteran VHA outpatients, 12% of women and 7% of men had more than six mental health visits in FY09; similarly, 7% of women 

versus 4% of men had 12 or more mental health visits in FY09. 

Among Women Veterans, the middle age group (45–64 years old) tended to use mental health care services more 

heavily. Among all outpatient women Veterans, 12% of 18–44 year olds, 14% of 45–64 year olds, and 3% of 

65–110 year olds had more than six mental health visits in FY09 (Figure 22). 

Figure 22 also shows that among the middle and older age groups of Veterans, a higher proportion of women 

than men had at least one mental health care visit in FY09 (39% vs. 33% in 45–64 year olds and 18% vs. 13% 

in 65–110 year olds). Within the 18–44 year old age group, a similar proportion of women and men used mental 

health care (41% vs. 42%). 

Within each age group, the same or a slightly higher proportion of women than men had more than six mental 

health visits in FY09. The difference is most pronounced in the 45–64 year old age group: Comparing women 

to men, more than six mental health visits were seen in 12% vs. 12% of 18–44 year olds, 14% vs. 10% of 45–64 

year olds, and 3% vs. 2% of those aged 65 years and older (Figure 22). 

20 
Fig 23. Proportion of women and men Veteran VHA outpatients by frequency of mental health visits,

by service–connected disability percent, FY09

 

 

 

Figure 23. Proportion of women and men Veteran VHA Outpatients by frequency of mental health visits, by service-connected 


disability ratings, FY09
 

Key:	 VHA—Veterans Health Administration; FY—Fiscal Year; 

SC—Service-connected 

0 

20 

40 

60 

80 

100 

No SC SC: 0–49 SC: 50–99 SC: 100 

Number 

of Visits 

% VHA Outpatients 

Women

Men

Women

Men

Women

Men

Women

Men 

0 Notes:	 See Technical Appendix for an explanation of how 

Veterans were identified in data, and how mental health 

1 	 utilization was ascertained, and for information on 

missing SC values. 

2–6 Cohort:	 Women and men Veteran VHA outpatients with nonmissing SC values in FY09. Women: N=286,653; Men: 

7+ N=4,739,888. 

Sources: WHEI analysis of ADUSH Monthly Enrollment File, FY09; 

VA outpatient utilization file (SE), FY09. 

SC Disability Rating (Percent) 

Implications 

Women Veterans Sourcebook Vol. 1: Utilization 

Among those women Veteran VHA patients who have mental 

illness, many use mental health services. Those who use mental health services 


tend to make many visits, suggesting that mental health care for women often 


requires high-intensity services. 


Figure 23 examines relationships between mental health utilization, service-connected 

(SC) disability status, and gender. While many women with no SC disability 

rating, or with an SC disability rating of 0–49 percent, use mental health clinics 

(30% and 32%, respectively), a substantially higher proportion of women with 

an SC disability rating of 50–99 percent or 100 percent used mental health clinics (51% and 68%, respectively). 

Similarly, women with an SC disability rating of 50 percent or higher were more often frequent users of mental 

health clinics: The proportion of women Veteran outpatients who visited mental health clinics more than six times 

in FY09 was 8% for those with no SC disability rating, 9% for those with a disability rating of 0–49 percent, 19% 

for those with a disability rating of 50–99 percent, and 33% for those with a disability rating of 100 percent. 

Figure 23 also shows that within each SC disability rating category (No SC, 0–49, 50–99, and 100 percent), a 

higher proportion of women than men used VHA mental health care in FY09 (No SC: 30% vs. 19%; 0–49 

percent: 32% vs. 24%; 50–99 percent: 51% vs. 44%; 100 percent: 68% vs. 52%). Within each SC disability rating category, a higher proportion of women than men had more than six mental health visits in FY09 (No SC: 8% 

vs. 4%; 0–49 percent: 9% vs. 6%; 50–99 percent: 19% vs. 14%; 100 percent: 33% vs. 18%). 

Notes to interpretation: The diagnosis for which the Veteran received an SC disability rating may or may not be 

a mental health condition; our data indicate only the SC disability ratings and not the diagnosis (es) for which a 

rating was determined. 

Inpatient Admissions 

In FY09, 7% of women Veteran VHA patients had one or more inpatient stays (21,632 women). Among men 

Veteran patients, 9% had one or more inpatient stays (425,271 men). 

The proportion of women who had an inpatient stay increased with advancing age. Among women Veteran VHA 

patients 45–64 years old and among those 65–110 years old, 9% had an inpatient stay (Figure 24). 

21 
Women Veterans Sourcebook Vol. 1: Utilization

22

Overall, a lower proportion of women than men had an inpatient stay in FY09 (7% vs. 9%). However, in the oldest age group (65 years or greater), a slightly higher proportion of women than men had an inpatient stay (9% vs. 

8%) (Figure 24). 

Inpatient use also varied slightly by service-connected (SC) disability ratings. The proportion of women Veterans 

with a 100-percent SC disability rating who had an inpatient stay was particularly high (19%), compared to women with other SC disability ratings (Figure 25). The proportion of women and men Veterans with an inpatient stay 

was the same for patients without an SC disability rating (8%) and for patients with 100-percent SC disability 

rating (19%). For all other SC disability rating categories, a higher proportion of men used inpatient care in FY09.

Women Men

Age 

(Years)

18–44 5.1% 5.9%

45–64 8.9% 10.6%

65–110 9.3% 7.8%

Women Men

SC Disability 

 Rating (Percent)

No SC 7.5% 8.2%

SC: 0 6.6% 9.9%

SC: 1–49 4.8% 6.5%

SC: 50–99 7.8% 9.9%

SC: 100 19.1% 19.0%

Figure 24. Proportion of women and men Veteran VHA patients 

with at least one inpatient stay, by age group, FY09

Figure 25. Proportion of women and men Veteran VHA patients 

with at least one inpatient stay, by serviceconnected disability ratings, FY09

Key: VHA—Veterans Health Administration; FY—Fiscal Year; 

SC—Service-connected 

Notes: Inpatient use was ascertained based on any indication 

of any inpatient stay in FY09. See Technical Appendix 

for a complete list of inpatient source files used, for an 

explanation of how Veterans were identified in data, and for 

information on missing age values. 

Cohort: Women and men Veteran VHA users who have non-missing 

ages between 18 and 110 years old (inclusive) in FY09. 

Women: N=292,894; Men: N=4,846,792.

Sources: WHEI analysis of ADUSH Monthly Enrollment Files, FY09; 

VA inpatient utilization files (PTF), FY09.

Key: VHA—Veterans Health Administration; FY—Fiscal Year; 

SC—Service-connected 

Notes: Inpatient use was ascertained based on any indication 

of any inpatient stay in FY09. See Technical Appendix for 

an explanation of how Veterans were identified in data, 

for a complete list of inpatient source files used, and for 

information on missing SC values. 

Cohort: Women and men Veteran VHA users with non-missing SC 

values in FY09. Women: N=292,108; Men: N=4,838,232. 

Sources: WHEI analysis of ADUSH Monthly Enrollment Files, FY09; 

VA inpatient utilization files (PTF), FY09.

Notes to interpretation: As with the outpatient data discussed previously, the data on inpatient care in this section 

do not include fee-basis inpatient care.

Women Veterans’ Longitudinal Trends, FY00–FY09

Outpatient Care

Total Outpatient Care. As the number of women Veterans in VHA nearly doubled between FY00 and FY09, the 

proportion of those who used any outpatient service remained stable at around 98%. However, women Veterans’ 

average number of VHA outpatient visits per year increased from 16.1 in FY00 to 19.0 in FY09. The rising proportion of women Veterans using VHA outpatient services 12 or more times (40% in FY00 and 48% in FY09) 

may explain some of this increase. 

Face-to-Face Outpatient Care. The number of women Veterans in VHA with any face-to-face outpatient visit 

increased from 149,007 (FY00) to 278,959 (FY09). Over this period, the proportion of women receiving any 

face-to-face care varied slightly, between 93% and 95% (Figure 26). Little change occurred in the proportion of 

women Veterans who had exactly one visit, 2–6 visits, and 7–11 visits. The proportion of women Veterans with 
Fig 26

Fig 27

 

 

 

Figure 26. Number of women Veteran VHA patients by frequency of face-to-face outpatient visits, FY00–FY09 

100 Key:	 VHA—Veterans Health Administration; FY—Fiscal Year; 

# WV VHA Outpatients 

2000

2001

2002

2003

WV—Women Veterans 80 

2004

Notes:	 Multiple face-to-face visits with different clinic stop 

60 codes can occur on the same day. See Technical Appendix 

2005

for an explanation of how women Veterans were 

40 

2006

identified in data. 

Cohort: Women Veteran VHA users in year. N=292,921 in FY09. 20 

2007

Sources: WHEI analysis of ADUSH Monthly Enrollment Files, 

2008

2009

0 FY00–FY09; VA outpatient utilization files (SE), FY00– 

FY09. 

Number of Visits: 0 1 2–6 7–11 12+ 

 

 

 

 

Figure 27. Proportion of women Veteran VHA outpatients by frequency of total primary care visits, FY00–FY09 

Key:	 VHA—Veterans Health Administration; FY—Fiscal Year; 

0 

20 

40 

60 

80 

100 

% WV VHA Outpatients 

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009 

WV—Women Veterans 

Notes:	 Total primary care stop codes include 170, 171, 210, 301, 

310, 319, 323, 348, 350, 394, 322, and 704. See Technical 

Appendix for descriptive stop code names and for an 

explanation of how women Veterans were identified 

in data. 

Cohort:	 Women Veteran VHA outpatients in year. N=287,447 

in FY09. 

Sources: WHEI analysis of ADUSH Monthly Enrollment Files, 

FY00–FY09; VA outpatient utilization files (SE), 

FY00–FY09. 

Number of Visits: 0 1 2 3–5 6+ 

Women Veterans Sourcebook Vol. 1: Utilization 

12+ visits increased from 25% in FY00 to 29% in FY09. Likewise, the intensity of face-to-face use among women 

Veterans did not vary much between FY00 and FY09. Among women Veterans with at least one face-to-face visit, 

the average number of face-to-face visits was about the same in each year of the decade (11.3 in FY00 and 11.9 in 

FY09), dipping to a low of 10.2 per woman in FY06. 

Primary Care 

Total Primary Care (PC and WHC combined). The number of women Veterans using any primary care in VHA 

increased markedly, from 122,903 in FY00 to 257,705 in FY09. In addition, the proportion of all women Veteran 

outpatients who had at least one primary care visit increased from 79% in FY00 to 90% in FY09 (Figure 27). 

The proportion that received primary care at least two times was 58% in FY00 and 67% in FY09. The proportion 

that received primary care at least three times was 41% in FY00 and 48% in FY09. The proportion that received 

primary care at least six times was 13% in FY00 and 15% in FY09. 

Although more women were receiving care in VHA primary care clinics by FY09, women on average had about 

the same number of primary care visits in FY09 as in FY00. Among all women Veterans who received primary 

care, the average number of visits per woman Veteran was 3.5 in both FY00 and FY09. 

Primary Care Clinic (PC). The number of women Veterans who used primary care clinics (specifically excluding 

any primary care services received in women’s health clinics) in VHA increased from 104,777 (68% of all women 

23 
Fig 28 Fig 29

 

 

 

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009 

Figure 28. Proportion of women Veteran VHA outpatients by Figure 29. Proportion of women Veteran VHA outpatients by 

frequency of primary care clinic (PC) visits, frequency of women’s health clinic (WHC) visits, 

FY00–FY09 FY00–FY09 

100 100 % WV VHA Outpatients

80 

60 

40 

% WV VHA Outpatients

20

80 

60 

40 

20 

0 0 

Number of Visits: 0 1 2 3–5 6+ Number of Visits: 0 1 2 3–5 6+ 

Key: VHA—Veterans Health Administration; FY—Fiscal Year; WV—Women Veterans 

Notes: Primary Care (PC) stop codes include 170, 171, 210, 301, 310, 319, 323, 348, 350, and 394. Women’s Health Clinic (WHC) includes 

clinic stop codes 322 and 704. Clinic 322 is “Women’s Clinic” and clinic 704 (used much less frequently) is “Pap Test Clinic.” See 

Technical Appendix for descriptive stop code names and an explanation of how women Veterans were identified in data. 

Cohort: Women Veteran VHA outpatients in year. N=287,447 in FY09. 

Sources: WHEI analysis of ADUSH Monthly Enrollment Files, FY00–FY09; VA outpatient utilization files (SE), FY00–FY09. 

Women Veterans Sourcebook Vol. 1: Utilization 

Veteran outpatient users) in FY00 to 225,560 (79% of all women Veteran outpatient users) in FY09 (Figure 28). 

The increased proportions occur steadily in each year between FY00 and FY09, and at all levels of care (1, 2, 3–5, 

and 6+ PC visits per year). Between FY00 and FY09, the average number of PC visits by women Veterans who 

had at least one PC visit in a given year was constant (3.1 in FY00 and 3.0 in FY09). 

Women’s Health Clinic (WHC). Over the decade, the number of women Veteran outpatients receiving any primary 

care in WHCs increased markedly, from 45,827 (30%) in FY00 to 107,196 (37%) in FY09 (Figure 29). The 

average number of primary care visits in WHCs for women Veterans who had at least one WHC visit in a given 

year was nearly constant (2.3 in FY00 and 2.1 in FY09). 

Notes to Interpretation: As discussed on pages 15 and 18, there is substantial variability in how different VA facilities code primary care for women. Since 2005, a number of facilities are known to have started coding primary 

care received in WHCs with codes that fall under the PC definition used in this report. Thus, while estimates of 

“Total Primary Care” (the sum of PC and WHC) are reliable, the proportion of that care occurring in WHCs cannot be 

estimated with confidence at present. Planned changes in coding procedures for WHC are expected to improve the 

interpretability of future data for this specific type of care. 

Specialty Care for Women 

Gynecology (clinic stop code 404). Between FY00 and FY09, the proportion of women Veteran VHA outpatients 

who used the gynecology clinic varied slightly, ranging from 14% to 15%. The proportion of women Veteran 

VHA outpatient users who attended exactly one visit to a gynecology clinic was 9% in FY00 and 9% in FY09, 

with a low of 8% in FY07. Among women Veterans who attended gynecology clinic at least once, the average 

number of gynecology clinic visits per woman had been about 1.6 in each year, FY00 through FY09. 

24 
Fig 30

 

 

 

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009 

Figure 30. Proportion of women Veteran VHA outpatients by frequency of mental health care visits, FY00–FY09 

100 Key:	 VHA—Veterans Health Administration; FY—Fiscal Year; 

WV—Women Veterans 

% WV VHA Outpatients80 

60 

40 

20 

Notes: See Technical Appendix for an explanation of how 

women Veterans were identified in data and how mental 

health utilization was ascertained. 

Cohort: Women Veteran VHA outpatients in year. N=287,447 

in FY09. 

Sources: WHEI analysis of ADUSH Monthly Enrollment Files, 

FY00–FY09; VA outpatient utilization files (SE), 

0 FY00–FY09. 

Number of Visits: 0 1 2–6 7–11 12+ 

Women Veterans Sourcebook Vol. 1: Utilization 

Women’s Surgery (clinic stop code 426). As a proportion of all women Veteran VHA outpatients, women attending women’s surgery clinics was as small in FY09 as it was in FY00 (0.2% in both years), although the absolute 

number of women Veteran patients attending these clinics had almost doubled, from 322 women in FY00 to 555 

in FY09. 

Mental Health Care 

The number of women Veterans using any VHA mental health outpatient services increased between FY00 and 

FY09, from 43,739 to 105,780. This represents a sizable proportional increase among women Veteran outpatients, 

from 28% in FY00 to 37% in FY09 (Figure 30). The increased proportions occurred steadily in each year between 

FY00 and FY09, and at all levels of care (1, 2–6, 7–11, and 12+ mental health visits per year). Among women 

Veteran VHA patients using mental health clinics in a given year, the average number of visits fluctuated around 

nine visits per woman (9.3 in FY00 and 8.7 in FY09). 

Implications The proportion of women Veteran 

VHA patients who made one or more primary care visits 

increased between FY00 and FY09. This suggests that the 

VHA has been successful in its efforts to connect more 

women Veteran patients with primary care providers. 

Further, the proportion of women Veteran VHA patients 

who had one or more mental health visits increased between 

FY00 and FY09. This suggests that VHA innovations in the 

past 10 years, such as systematic screening for mental illness 

and embedded mental health providers in primary care 

settings, appear to have improved access to mental health 

services for women Veteran VHA patients. 

25 
Women Veterans Sourcebook Vol. 1: Utilization 

26 

 

 

 

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009 

Figure 31. Proportion of women Veteran VHA patients with at least one inpatient stay, FY00–FY09 

Key:	 VHA—Veterans Health Administration; FY—Fiscal Year; 

WV—Women Veterans; IP—Inpatient 

0 

20 

40 

60 

80 

100 

% WV VHA Patients

Notes: Inpatient use was ascertained based on any indication 

of any inpatient stay in the FY examined. See Technical 

Appendix for a complete list of IP source files used, 

and for an explanation of how women Veterans were 

identified in data. 

Cohort: Women Veteran VHA users in year. N=292,921 in FY09. 

Sources: WHEI analysis of ADUSH Monthly Enrollment Files, 

FY00–FY09; VA inpatient utilization files (PTF), 

FY00–FY09. 

IP Users Other VHA Users 

Fig 31

Inpatient Admissions 

The number of women Veteran VHA patients using VHA for inpatient services has grown from 14,665 in FY00 

to 21,632 in FY09. However, growth in the number of inpatient users has not been as rapid as growth in the total 

number of women Veteran patients over the decade. This means that the proportion of women Veteran patients 

who use inpatient services at least once during each year has decreased over this period, from 9% in FY00 to 7% 

in FY09 (Figure 31). 

Notes to interpretation: Among women Veteran VHA patients, the proportion using inpatient care decreased 

between FY00 and FY09. This could reflect the fact that the proportion of women aged 65 or older decreased 

over the same time interval (Figure 5); as Figure 24 shows, older women Veterans more commonly use inpatient 

services. 
Women Veterans Sourcebook Vol. 1: Technical Appendix 

27 

Part 3: Technical Appendix
 

1. Data Sources
 

Data for this Sourcebook came from centralized VHA administrative data files spanning a 10-year period from 

Fiscal Year 2000 through Fiscal Year 2009 (FY00–FY09). The three source files used to create the Sourcebook 

database are: 

ADUSH: Monthly VHA Enrollment data files maintained by the office of the Assistant Deputy Under Secretary for Health, containing records of sociodemographic characteristics and other person-level variables (sex, 

Veteran status, VHA user status, date of birth, service-connected disability status, etc.). 

SE/SF: VHA outpatient encounter files (SAS Medical Dataset from VHA’s National Patient Care Database). 

The SE file contains a record for every encounter the patient makes to VHA (e.g., clinic visits, telephone 

encounters, lab tests, radiology encounters, etc.); there can be more than one encounter on a given day. The SF 

file rolls up records of SE file encounters into one record per day of care. 

a.	 MDPPRD.MDP.SAS.SEyy (SE) 

b.	 MDPPRD.MDP.SAS.SFyy (SF) 

PTF: VHA inpatient stay files, which contain a record for every admission to a VHA facility (SAS Medical 

Dataset from VHA’s National Patient Care Database) 

a.	 MDPPRD.MDP.SAS.PMyy 

b.	 MDPPRD.MDP.SAS.PMOyy 

c.	 MDPPRD.MDP.SAS.XMyy 

d. MDPPRD.MDP.SAS.CENSUS.PMyy 

e.	 MDPPRD.MDP.SAS.CENSUS.PMOyy 

f.	 MDPPRD.MDP.SAS.CENSUS.XMyy 

All programming was performed using SAS 9.2©, and all programs were independently validated by at least one 

other data analyst. Data presented in this report were analyzed for program evaluation purposes.16 

2. Cohort Creation 

The Sourcebook reports on characteristics of women and men Veterans17 who, based on the ADUSH Enrollment 

File, used VHA for outpatient and/or inpatient care and/or fee-basis services and/or non-VA contract care and/or 

16	 These program evaluation analyses are for non-research purposes. Research publications and presentations derived from these data are 

covered by an approval by the Stanford University Institutional Review Board and the VA Palo Alto Health Care System Research and 

Development committee. 

17	 Non-Veterans who use VHA services are not included in the current report. Previous work (Frayne et al., 2008) has found that nearly 

half the women in the SE data files are non-Veterans, and the majority of these non-Veterans are employees. Employees appear in the 

database primarily due to their encounters with Employee Health (e.g., for mandatory tuberculosis screening or for influenza vaccines). 

Other non-Veterans who use VHA services include some active duty military personnel and some eligible spouses of Veterans. They are 

not a focus of this volume of the Sourcebook. 
Women Veterans Sourcebook Vol. 1: Technical Appendix 

pharmacy services at least once in the year being examined, from FY00–FY09.18 

Starting with the record-level files cited above, we created person-level analytical files with one observation for 

each person—identified by scrambled Social Security Number—found in the data sources. Our complete 

Women’s Health Evaluation Initiative (WHEI) Master database includes the following types of people: 

•	 Users and non-users of VHA care, 

•	 Veterans and non-Veterans, and 

•	 Women and men. 

Year-specific variables indicate whether an individual was a VHA user or a Veteran in a given year, since these 

are characteristics that may legitimately change over time. Single variables were created for sex and date of birth, 

which are constant across years. Table 2.1 shows the number of people in the WHEI Master database in each year 

examined: the number within the WHEI Master database who were VHA users (Veterans and non-Veterans 

combined), and the number within the WHEI Master database who were Veteran VHA users.19 

Table 2.1 Number of people in WHEI Master database (overall, and Veteran VHA users) by year 

Fiscal Year Total in WHEI Master database (women and men, 

Veterans and non-Veterans, VHA users and non-users) Total Veteran VHA users* 

2000 5,249,069 3,395,205 

2001 6,379,138 3,843,832 

2002 7,180,757 4,246,084 

2003 7,581,489 4,505,433 

2004 7,915,775 4,677,720 

2005 8,206,947 4,802,582 

2006 8,238,168 4,901,827 

2007 8,394,406 4,950,501 

2008 8,563,192 4,998,184 

2009 8,869,648 5,140,379 

* These numbers include those with missing sex values. For example, in FY09, there are 5,140,379 Veteran VHA users in the 

WHEI Master database. This is 589 more people than the 5,139,790 women plus men Veteran users reported in Source 

Book figures, because of missing data: Gender was not available for 589 Veteran users in FY09. 

18 Because the ADUSH file counts use of fee-basis services, non-VA contract care, and pharmacy services as instances of VHA utilization, 

a small number of patients whose only use of VHA services is through fee-basis care, non-VA contract care, or outpatient pharmacy 

services are included in the cohort examined in this Sourcebook. In FY09, only 1.8% (5,204) of women Veterans who were identified 

as VHA users by ADUSH had no utilization of VHA outpatient or inpatient care (and thus were presumably VHA users by virtue of 

fee-basis, contract, or pharmacy services only). Because the analyses in this Sourcebook do not draw upon VHA’s fee-basis, contract 

care, and pharmacy files, we do not explicitly characterize these types of utilization. 

19 The definitions of variables for woman, Veteran, and VHA user are intended to replicate as closely as possible the definitions used by 

the VHA Support Service Center (VSSC) in their data report cubes, so as to maximize compatibility between data appearing in various 

VHA reports. There is a slight difference in the number of women Veteran users that we report and the number reported by VSSC 

(e.g., a difference of approximately 40 women Veteran VHA users in FY09). 

28 
Women Veterans Sourcebook Vol. 1: Technical Appendix 

29 

3. Algorithms for Sociodemographic Characteristics 

The WHEI Master database created for the Sourcebook includes person-level sociodemographic indicators derived 

from data in the ADUSH Enrollment file (in some cases supplemented with data from the SE/SF files), for each 

year from FY00–FY09. These variables include use of VHA services, Veteran status, sex, date of birth, and serviceconnected disability status. Data sources are described in Section 1 of this Technical Appendix. 

3.1 VHA Users 

VHA users were identified from ADUSH files using a year-specific user variable labeled “FYyy,” and the following cost variables: 

2000–2001: CNHCOST; FEECOST; LTCCOST; MEDCOST; NVACOST; OPCCOST; PSYCOST; 

SURCOST 

2002–2007: DSSCNHCOST; DSSFEECOST; DSSLTCCOST; DSSMEDCOST; DSSNVACOST; 

DSSOPCCOST; DSSPSYCOST; DSSSURCOST; CNHCOST; FEECOST; LTCCOST; 

MEDCOST; NVACOST; OPCCOST; PSYCOST; SURCOST 

2008–2009: DSSCNHCOST; DSSFEECOST; DSSLTCCOST; DSSMEDCOST; DSSNVACOST; 

DSSOPCCOST; DSSPSYCOST; DSSSURCOST; ARCCNHCOST; ARCFEECOST; 

ARCLTCCOST; ARCMEDCOST; ARCNVACOST; ARCOPCCOST; ARCPSYCOST; 

ARCSURCOST 

A person was considered to be a VHA user in a particular fiscal year if both the following were true: 

1. “FYyy=1” for the specified year AND 

2. Sum of all cost variables is >0 for the specified year. 

All others were non-users (1/0 variable). The term “user” is synonymous with the term “patient” in this report. 

3.2 Veterans 

Two methods were employed to identify Veterans (1/0 variable) in each year over the 10-year period. Because 

true changes in Veteran status can occur, we did not require that Veteran status for a given individual be consistent across years. 

FY03–FY09: Identified using variables labeled “PRIO1_8” and “ELIG.” 

A patient is considered a Veteran if either of the following is true: 

1. PRIO1_8 value is NOT missing OR 

2. PRIO1_8 value IS missing, AND the first letter of the ELIG variable value is NOT=“N” 

FY00–FY02: In these years, the variable PRIO1_8 was not available in the ADUSH file. Therefore, we 

used variables labeled “MATCH” and “ELIG.” 

A patient is considered a Veteran if either of the following is true: 

1. MATCH NOT=Cost Only, OR 

2. The first letter of the ELIG value is NOT=“N” 

3.3 Sex 

Creating a definitive sex variable for each person involved three steps. 

In Step 1, we created a sex variable for each year. Two different ADUSH variables were employed to identify 

sex (female/male) in each year over the 10-year period. 
Women Veterans Sourcebook Vol. 1: Technical Appendix 

30 

FY06–FY09: Identified using variable labeled “SEX_BEST”20 

FY00–FY05: In the years prior to “SEX_BEST” becoming available, we used variable labeled “SEX.” 

In Step 2, we assigned a single, constant sex value that is applied to each of the 10 years. We did this to address 

the fact that the sex variable may be missing (not coded) in some years, or that a patient’s sex could be discrepant across years. Specifically, we used the most recent (closest to FY09) non-missing value for sex. This step 

reduced the number of people who had missing sex values and assured that an individual was assigned the same 

value for sex in every year. The rationale for using the most recent value is the assumption that more recent 

values reflect “corrected” values.21 

In Step 3, we addressed the issue of any remaining instances of missing values for the sex variable. Specifically, 

for any individuals whose sex value was still missing at the end of Step 2, we assigned the most recent nonmissing value of sex from the SF outpatient utilization file. 

See Section 5.1 for the proportion of people who had at least one instance of discrepant values across the 

10-year period. See Section 5.2 for the proportion of people in each fiscal year who were missing sex values at 

Step 1, at Step 2, and at Step 3. 

3.4 Age 

Creating a definitive age variable for each person involved four steps. 

In Step 1, we created a date of birth variable for each year using ADUSH data. 

FY06–FY09: Identified using variable labeled “DOB_BEST” 

FY00–FY05: In the years prior to DOB_BEST becoming available, we used the variable labeled “DOB.” 

In Step 2, we assigned a single, constant DOB value that is applied for each of the 10 years. We did this to 

address the fact that the DOB variable may be missing (not coded) in some years, or that a patient’s DOB 

could be discrepant across years, or that the patient’s DOB could yield an out-of-range age (while an age of 17 

years or 111+ years is theoretically possible, we assumed that the very small number of instances of ages <18 

years or >110 years reflected data errors and were thus invalid). Specifically, we used the most recent (closest 

to FY09) non-missing, within-range value for DOB. This step reduced the number of people who had missing or out-of-range DOB values and assured that an individual was assigned the same value for DOB in every 

year. The rationale for using the most recent value is the assumption that more recent values reflect “corrected” 

values. 

In Step 3, we addressed the issue of any remaining instances of missing values for the DOB variable. Specifically, for any individuals whose DOB value was still missing at the end of Step 2, we assigned the most recent 

non-missing, within-range value of DOB from the SF outpatient utilization file. 

In Step 4, we calculated age in a given year by subtracting the DOB from the first day of the fiscal year. 

20	 Since FY06, the VA Information Resource Center (VIReC) Vital Status files include derived sociodemographic variables (SEX_BEST, 

DOB_BEST, DOD_BEST). These variables incorporate information from multiple data sources and thus represent more complete/ 

accurate variables. ADUSH files use these variables from FY06 onward. 

21	 There were very few cases of discrepant sex in ADUSH: In only 0.12% of cases was there inconsistency in coding of female/male status 

across years. Instances of a change in the patient’s sex from one year to another year probably reflect data entry errors: The wrong sex is 

entered one year, and then the error is corrected in a subsequent year. True changes in the patient’s sex (e.g., through surgery) are likely 

less common. While these databases do not allow us to distinguish between data entry errors and true changes in sex, in both cases it 

seems reasonable to assign the last-recorded sex to the patient. 
Women Veterans Sourcebook Vol. 1: Technical Appendix 

31 

  

See Section 5.2 for the proportion of people in each fiscal year who were missing DOB value at Step 1, at 

Step 2, and at Step 3. 

3.5 Service-Connected Disability Status 

The service-connected (SC) disability status variable is based on the variable “SCPER” in the ADUSH file. Like 

the Veteran variable, SCPER can potentially change across years for legitimate reasons (i.e., if the individual’s 

SC disability rating changes). If the SCPER variable was populated in ADUSH, we assigned the ADUSH 

SCPER value to the individual. If the SCPER variable was missing, we considered the individual as not having 

an SC disability status (i.e., the individual was either a non-SC Veteran, or a non-Veteran), except in the small 

number of instances where the ELIG variable in ADUSH indicated that the individual was an SC disabilityrated Veteran. In the latter case, we counted the SCPER variable as missing, because true SC status could not 

be resolved. See Section 5.3.c for data quality control checks supporting this approach. 

4. Algorithms for Utilization 

Outpatient Utilization 

Outpatient utilization variables are derived from the SE outpatient encounter files. Clinic “stop codes” (codes 

indicating clinic type) identify the clinical setting in which the patient received care.22 This report examines the 

following specific types of outpatient care: 

•	 Total Outpatient Care refers to any type of outpatient care (i.e., all clinic stop codes are considered outpatient care). 

•	 Face-to-Face Outpatient Care represents face-to-face care with a clinician (such as primary care visits, mental 

health visits, other specialty care visits, rehabilitation care visits, etc.). Other types of encounters that do not 

involve a face-to-face visit with a clinician (such as lab tests, radiology tests, and telephone encounters) are 

not included in this type of care. 

•	 Primary Care Clinic refers to primary care received in a general medical clinic. In addition to providing 

preventive care and care for gender-neutral conditions, such clinics sometimes provide gender-specific care 

to women (such as cervical cancer screening and breast exams), and sometimes refer women to a different 

clinic for such gender-specific services. 

•	 Women’s Health Clinic refers to primary care services received in a clinic designed specifically for women. 

Such clinics sometimes provide comprehensive primary care services to women (i.e., preventive health care, 

care for gender-neutral conditions, and care for gender-specific conditions), and sometimes provide care 

only for gender-specific conditions (such as cervical cancer screening and breast exams for women who get 

most of their primary care in non-gender-specific Primary Care Clinics). Note: There is variability in how 

different VA facilities code primary care for women. Prior work has quantified this variability by examining 

the percent of women at a facility who had at least one women’s health clinic visit (stop code 322). In FY09, 

this percent ranged from 0–69% across facilities. Some facilities known to have women’s health clinics 

had no patients with 322 coded, suggesting variability in how the code was used and interpreted.23 This is 

consistent with the fact that, since 2005, a number of facilities are known to have started coding primary 

22	 “Stop codes” are clinic type codes, which are used to identify outpatient care in VHA. Each type of clinic has a unique three-digit code. 

The codes are entered into the local VHA VISTA system for each patient encounter (e.g., a clinic visit, a radiology procedure, a clinical 

telephone encounter). The data gathered through VISTA are aggregated into SE files in the national SAS Medical Datasets. 

23	 Herrera L, Iqbal S, Hayes PM, Phibbs CS, Friedman SA, Laungani L, Berg E, Frayne SM. Can Stop Codes Identify Women’s Health Care? 

Poster presentation at VA HSR&D Women’s Health Services Research Conference in Washington, D.C., July 2010. 
Women Veterans Sourcebook Vol. 1: Technical Appendix 

32 

care received in women’s health clinics with codes that fall under the PC definition employed here. This 

leads to an important caveat about WHC data in this report: While estimates of “Total Primary Care” (the 

sum of PC and WHC) are reliable, the proportion of that care occurring in women’s health clinics cannot 

be estimated with confidence at present. Planned changes in coding procedures for women’s health clinic are 

expected to improve the interpretability of future data for this specific type of care. 

•	 Women’s Specialty Care refers to gynecology clinic and ambulatory surgery clinic for women. 

•	 Mental Health Care refers to care received in mental health clinics (individual or group mental health settings). 

For each type of care, in the WHEI Master database, we created a count of the total number of encounters occurring for a patient in one fiscal year (for each year FY00–FY09), regardless of whether those encounters occurred 

on the same day. Of note, while we exclude duplicate records (encounters by the same person on the same day at 

the same facility to the same clinic stop code, representing erroneous double-entry of a record), more than one 

encounter may legitimately occur on a single day. For example, a patient may visit a primary care clinic, cardiology clinic, podiatry clinic, and the outpatient laboratory all on the same day; using our approach, all but the lab 

visit would be counted toward the “face-to-face outpatient care” tally, and the primary care visit would be counted 

toward the “primary care” tally. It is important to capture all visits occurring on each day (rather than simply 

counting total number of days on which care was received), because some patients intentionally try to consolidate 

as much care as possible on a single day (e.g., to reduce the need to travel to the VHA or to reduce time away from 

work or caregiving). The frequency of duplicate records is described in Section 5.4. 

Outpatient variables stop codes. The specific clinic stop codes from the SE file used to create counter variables for 

each type of care are listed here. 

4.1 Outpatient care encounters 

Any stop code. 

4.2 Face-to-face outpatient care encounter 

101,102,116,117,118,119,121,122,123,124,125,130,131,144,149,152,153,156,157,159,160,165,170,171, 

172,173,174,175,176,177,180,185,186,187,188,190,191,195,196,197,198,201,202,203,204,205,206,209, 

210,211,214,215,217,218,219,220,230,290,291,292,293,294,295,296,301,302,303,304,305,306,307,308, 

309,310,311,312,313,314,315,316,317,318,319,320,321,322,323,327,328,329,330,331,332,333,334,335, 

336,337,348,349,350,351,352,370,372,373,394,401,402,403,404,405,406,407,408,409,410,411,412,413, 

414,415,416,418,419,420,422,426,427,429,430,431,432,433,434,435,436,437,438,439,457,480,501,502, 

503,504,505,506,509,510,512,513,514,516,519,520,521,523,524,525,529,531,532,533,534,538,540,547, 

550,551,552,553,554,556,557,558,559,560,561,562,563,564,565,566,567,568,571,572,573,574,576,577, 

578,580,581,582,583,589,590,591,593,594,595,596,602,603,604,606,607,608,610,650,651,652,653,654, 

655,656,658,681,691,704,707,708,709,712,713,716,718,725,726,727,728,730,731 

In addition, the count of face-to-face encounters excludes records where the CPT code is between 80048 and 

89399 (laboratory codes) for all SE variables CPT1 through CPT20. 

4.3 Primary care clinics (separate variable for each stop code) 

170 Home-based Primary Care
 

171 Nursing (RN or LPN) 


210 Spinal Cord Injury
 

301 General Internal Medicine 


318 Geriatric Clinic
 
Women Veterans Sourcebook Vol. 1: Technical Appendix 

33 

319 Geriatric E and M 

323 Primary Care Medicine24 

348 Primary Care Group 

350 Geriatric Primary Care 

394 Med Specialty Group (Primary stop code only) 

4.4 Women’s health clinics (separate variable for each stop code) 

322 Women’s Clinic25 

704 Pap Test Clinic 

4.5 Specialty care in clinics designed for women (separate variable for each stop code) 

404 Women’s Specialty Care 

426 Women’s Surgery 

4.6 Mental health care clinics 

125 Social Work Svc 

156 HBPC-Psychologist 

157 HBPC-Psychiatrist 

165 Bereavement Counseling 

173 Home-based Primary Care-Social Work 

292 Observational Psychiatry 

501 Homeless Mentally Ill 

502 Mental Health-Individual 

503 Mental Health Residential Care 

504 IPCC Medical Center VI 

505 Day Treatment-IND 

506 Day Hospital-IND 

509 Psychiatry-IND 

510 Psychology (PSO)-Individual 

512 Mental Health Consultation 

516 PTSD Group 

519 Subst. Abuse / Teams 

524 Active Duty Sex Trauma 

525 Women’s Stress Disorder Treatment Teams 

529 Health Care for Homeless Veterans (HCHV)/HMI 

531 Mental Health Primary Care Team 

532 Psychosocial Rehabilitation Individual 

533 Mental Health Intervention Biomedical Care-Individual 

534 Mental Health Integrated Care 

538 Psychological Testing 

540 PTSD Clinical Team (PCT) Post-Traumatic Stress-Individual 

550 Mental Hygiene-Group 

551 IPCC Community Clinic 

552 Mental Health Intensive Case Management 

553 Day Treatment-Group 

24 323 is the stop code most commonly used for primary care clinics.
 

25 322 is the stop code most commonly used for women’s health clinic; 704 is rarely used.
 
Women Veterans Sourcebook Vol. 1: Technical Appendix 

34 

 

554 Day Hospital Group 

557 Psychiatry-Group 

558 PSYCHOLOGY-GROUP 

559 PSY/SOC REHAB-GRP 

560 SUBST ABUSE-GRP 

561 PCT PTSD-GRP 

562 PTSD-INDIVIDUAL 

563 MH PRIM CARE TEAM-GRP 

564 MH TEAM CASE MGT 

565 MH MEDICAL CARE ONLY-GRP 

566 MH RISK-FACTOR-REDUCTION ED GRP 

567 MHICM GRP 

568 MENTAL HEALTH COMPENSATED WORK THERAPY/ SUPPORTED EMPLOYMENT 

(CWT/SE) Face-to-Face 

571 Serv-MH, IND 

572 Serv-MH, GRP 

576 PSYCHOGERIATRIC CLINIC, IND 

577 PSYCHOGERIATRIC CLINIC, GRP 

578 PSYCHOGERIATRIC DAY PROGRAM 

580 PTSD DAY HOSP 

581 PTSD DAY TREAT 

582 PRRC IND 

583 PRRC GRP 

589 NON-ACTIVE DUTY SEX TRAUMA 

713 GAMBLING ADDICTION 

725/593 RESIDENTIAL REHABILITATION TREATMENT PROGRAMS (RRTP) OUTREACH SERVICES 

726/594 RESIDENTIAL REHABILITATION TREATMENT PROGRAMS (RRTP) AFTERCARE– 

COMMUNITY 

727/595 RESIDENTIAL REHABILITATION TREATMENT PROGRAMS (RRTP) AFTERCARE–VHA 

728/596 RESIDENTIAL REHABILITATION TREATMENT PROGRAMS (RRTP) ADMISSION 

SCREENING SERVICES 

730 RESIDENTIAL REHABILITATION TREATMENT PROGRAMS (RRTP)–GENERAL CARE 

[Event Capture System (ECS) USE ONLY] 

Inpatient Utilization 

The inpatient variable is a yes/no variable that indicates whether the person was on inpatient status at any time 

during a given year. Note that if a stay extended across fiscal years, the individual would be considered to have 

been on inpatient status during more than one year. We used the six inpatient data files listed in Section 1 of the 

Technical Appendix to identify inpatient stays. 
Women Veterans Sourcebook Vol. 1: Technical Appendix 

5. Data Quality Control 

5.1 Consistency 

Within-year consistency. We confirmed that ADUSH variables (FYyy, ELIG, MATCH, PRIO1_8, SEX, SEX_ 

BEST, DOB, DOB_BEST, and SCPER) had consistent values for an individual within any given year. This 

allowed us to create datasets with a single record each year for each person out of multi-record ADUSH files 

without needing to reconcile discrepant values. 

Cross-year consistency of sex variable. Each individual in the database has between 1 and 10 different yearspecific sex variables, depending on the number of years in which they were VHA patients (FY00–FY09). We 

investigated how many people had inconsistent values for sex. We calculated the proportion of all patients in 

the database (FY00–FY09) whose records were either all consistent (100%), mostly consistent (51–99% of 

records indicate one sex), or consistent half the time (50% of records indicate one sex). 

The results are in Table 5.1. There were very few cases of discrepant sex; in only 0.12% of cases was there 

inconsistency in coding of female/male status across years. Most instances of a change in the patient’s sex from 

one year to another year probably reflect data entry errors: The wrong sex is entered one year, and then the 

error is corrected in a subsequent year. True changes in the patient’s sex (e.g., through surgery) are likely less 

common. While these databases do not allow us to distinguish between data entry errors and true changes in 

sex, in both cases it seems reasonable to assign the last-recorded sex to the patient. 

Table 5.1 Percent of individuals in database, by cross-year consistency of sex variable, FY00–FY09 

Consistency across 10 years (FY00–FY09) 

100% 51–99% 50% 

SEX 99.87% 0.11% 0.01% 

Note: Inconsistency levels of the sex variable reflect the data before a single, cross-year 

sex variable was created, i.e., this data check occurred at Step 1 of the sex variable 

creation process (see Table 5.2.a). 

Although the proportion of people in the database with inconsistent sex values is small, accurately ascertaining 

whether patients are female or male is critical to the mission of this report. Section 3.3 describes the algorithm 

used to improve consistency and completeness in the sex variable. 

5.2 Missing Data 

Missing data were assessed for all analytical variables. Table 5.2.a and 5.2.b show the proportion of people in 

the database who were missing data for the final sex and the final age variables. Table 5.2.c shows the proportion of people in the database who were missing data for service-connected disability status. None of the 

individuals in our cohort of Veteran users of VHA services are missing data for the user or Veteran variables. 

Table 5.2.a shows the proportion of observations that are missing sex in each year before we completed steps 

to supplement from other years of ADUSH data and the SF file (see section 3.3 for more explanation of these 

steps). These steps reduced the number of people who were missing a sex value in the final analytical variable. 

It is important to note that the count of women and men in our cohort does not include the small group of 

patients (589 in FY09) whose sex could not be determined. 

35 
Women Veterans Sourcebook Vol. 1: Technical Appendix 

Table 5.2.a Number of individuals (among Veteran VHA user cohort—men and women) missing a sex value in each fiscal year, 

by step of sex variable creation algorithm (see Section 3.3 for complete algorithm) 

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 

Step 1: Year- # missing 325,007 366,838 392,104 66,547 90,840 79,310 243 384 1,521 1,421 

specific sex 

value (%) 8.9% 8.8% 8.6% 1.5% 1.9% 1.7% 0.0% 0.0% 0.0% 0.0% 

Step 2: # missing 203,739 230,762 213,013 6,816 10,135 7,211 181 275 358 1,414 

Single sex 

value (%) 5.6% 5.6% 4.7% 0.2% 0.2% 0.2% 0.0% 0.0% 0.0% 0.0% 

Step 3: # missing 10,668 4,683 2,918 1,404 3,252 816 180 274 313 589 

Supplement 

with SF (%) 0.3% 0.1% 0.1% 0.0% 0.1% 0.0% 0.0% 0.0% 0.0% 0.0% 

Key: VHA—Veterans Health Administration; SF—NPCD Outpatient utilization file. 

Note: In Step 1, we created a sex variable for each year using ADUSH data. In Step 2, for people who were missing a sex value in a given year, 

we assigned the most recent non-missing sex value from the ADUSH file. In Step 3, we assigned the most recent non-missing sex value 

from the SF outpatient utilization file. For example, in FY00, 325,007 people (9% of Veteran VHA patients in FY00) were missing sex values in 

the FY00 ADUSH file. After assigning sex values found in other years of the ADUSH file, 203,739 people still had missing values (down to 6% 

of Veteran VHA patients in FY00). Extending the search to the SF file reduced the number of people with missing values to 10,668 (0.3% of 

Veteran patients in FY00). 

Table 5.2.b Number of individuals (among Veteran VHA user cohort—women and men) missing a date of birth (DOB) value 

in each fiscal year, by step of DOB creation algorithm (see Section 3.4 for complete algorithm) 

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 

Step 1: Yearspecific DOB 

value 

# missing 87,954 60,531 93,740 66,517 90,863 79,444 213 350 1,494 1,397 

(%) 2.6% 1.6% 2.2% 1.5% 1.9% 1.7% 0.0% 0.0% 0.0% 0.0% 

Step 2: 

Single DOB 

value 

# missing 17,674 12,514 10,093 6,845 10,149 7,235 192 273 375 1,498 

(%) 0.5% 0.3% 0.2% 0.2% 0.2% 0.2% 0.0% 0.0% 0.0% 0.0% 

Step 3: 

Supplement 

with SF 

# missing 9,478 3,968 2,368 1,438 3,268 845 190 272 330 670 

(%) 0.3% 0.1% 0.1% 0.0% 0.1% 0.0% 0.0% 0.0% 0.0% 0.0% 

Key: 

Note: 

VHA—Veterans Health Administration; DOB—date of birth; SF—NPCD Outpatient utilization file. 

In Step 1, we created a date of birth variable for each year using ADUSH data. In Step 2, for people who were missing a date of birth 

in a given year, we assigned the most recent non-missing, within-range date of birth from the ADUSH file. In Step 3, we assigned the 

most recent non-missing, within-range value of DOB from the SF outpatient utilization file. For example, in FY00, 87,957 people (2.6% 

of Veteran VHA patients in FY00) were missing date of birth in the FY00 ADUSH file. After assigning within-range dates of birth found 

in other years of the ADUSH file, 17,674 people still had missing values (down to 0.5% of Veteran VHA patients in FY00). Extending the 

search to the SF file reduced the number of people with missing values to 9,478 (0.3% of Veteran patients in FY00). 

Table 5.2.c Number (and proportion) of cohort (Veteran VHA users N=5,140,379 in FY09) missing a service-connected 

value in each fiscal year (see Section 3.5 for complete algorithm) 

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 

# 34,054 21,719 68,162 58,333 62,705 59,064 66,332 75,583 88,151 9,450 

% 1% 1% 2% 1% 1% 1% 1% 2% 2% 0% 

Note: After creating a service-connected variable using the SCPER and ELIG variables, there were 9,450 Veteran VHA users missing a 

service-connected value in FY09. 

36 
Women Veterans Sourcebook Vol. 1: Technical Appendix 

5.3 Agreement between variables providing similar information 

In FY06–FY09, an additional sex variable (SEX_BEST) and additional DOB variable (DOB_BEST) are 

available in the ADUSH file, derived from Vital Status files. Tables 5.3.a and 5.3.b compare the number 

of missing observations between the two variables. Table 5.3.c investigates whether individuals missing values 

of SCPER have ELIG values that are consistent with not carrying a service-connected disability status. 

Cross tabulations are provided below: ariable: V SEX 

Table 5.3.a Completeness of SEX vs. SEX_BEST from ADUSH file, among Veterans and non-Veterans, VHA users, 

and non-users of VHA, FY09 

Variable: SEX_BEST 

Missing Female Male Total 

Missing 180,248 60,397 43,219 284,864 

Female 4,361 548,679 1,687 554,727 

Male 31,792 1,685 7,996,580 8,030,057 

Total 217,401 610,761 8,041,486 8,869,648 

Note: Missing values include the values “not found” and “unknown.” 

Interpretation of 5.3.a: The variable SEX_BEST is missing for fewer people than the variable SEX. Note 

also that of the 284,864 people who were missing information on whether they were female or male using 

the SEX variable, 60,397 are identified as women using SEX_BEST. This compares to only 4,361 identified as female using SEX where SEX_BEST is missing. ariable: V DOB

Table 5.3.b Completeness of DOB vs. DOB_BEST from ADUSH file, among women and men Veteran VHA users, FY09 

Variable: DOB_BEST 

Missing Present Total 

Missing 529 23,783 24,312 

Present 868 5,115,199 5,116,067 

Total 1,397 5,138,982 5,140,379 

Interpretation of 5.3.b: The variable DOB_BEST is missing for fewer people than the variable DOB. 

Table 5.3.c Non-service-connected in ELIG vs. missing SCPER among all VHA users (Veterans and non-Veterans), FY09 

 

Variable: ELIG 

Veteran, serviceconnected Veteran, not service-connected* Non-Veteran** Value 

missing Total 

ariable: V

SCPER 

Value present # 2,103,679 50,498 7,261 0 2,161,438 

Value missing # 9,450 2,959,751 316,132 0 3,285,333 

Total # 2,113,129 3,010,249 323,393 0 5,446,771 

* 

** 

Includes the following values of ADUSH ELIG variable: A2, A4, A5, A6, AN, C2, C5, G5, X4, X5, U5, C, U6, A, C4, C6, G, G2, G4, G6, U, U2, 

X, X2, X6. 

Includes all ELIG values beginning with N. 

37 
Table 5.4 Clinic stops with high rates of duplicate records 

Stop code CLINIC STOP Frequency Proportion of 

all duplicates 

108 LABORATORY 3,674,844 45.9 

323 PRIMARY CARE/MED 871,032 10.9 

560 SUBST USE DISORDR GRP 281,066 3.5 

502 MENTAL HEALTH-IND 218,652 2.7 

105 X-RAY 192,554 2.4 

547 INTNSE SUB USE DSRDER GRP 161,366 2.0 

130 EMERGENCY DEPT 139,789 1.8 

180 DENTAL 130,695 1.6 

103 TELEPHONE TRIAGE 117,844 1.5 

513 SUBST USE DISORDR IND 111,303 1.4 

523 OPIOID SUBSTITUTION 91,972 1.2 

407 OPHTHALMOLOGY 83,613 1.0 

553 DAY TRMT-GRP 81,527 1.0 

408 OPTOMETRY 78,175 1.0 

147 TELEPHONE/ANCILLARY 60,412 0.8 

202 REC THERAPY SERVICES 55,020 0.7 

561 PCT PTSD-GRP 54,930 0.7 

559 PSY/SOC REHAB-GRP 52,466 0.7 

107 EKG 51,944 0.7 

150 COMPUTER TOMOGRAPHY (CT) 51,300 0.6 

Women Veterans Sourcebook Vol. 1: Technical Appendix 

Interpretation of 5.3.c: Most (99.0%, or 2,959,751) VHA patients who are missing SCPER have an 

ELIG value that suggests they do not have a service-connected disability status. This includes people 

whose ELIG value explicitly indicated no service-connected disability status, as well as those whose ELIG 

value explicitly indicated that they were not a Veteran. 

5.4 Analysis of duplicate stop codes 

The counts of stop code utilization excluded duplicate stop codes (see Section 4). Among all FY09 encounters that were duplicates, we examined which stop codes accounted for the highest volume of duplicates. Table 5.4 shows that 8.6% of all outpatient encounters in FY09 were duplicates. Nearly half these 

duplicates were laboratory (stop code 108). This is not surprising since patients often may have more than 

one lab service on a given day. The second most common duplicate stop code was primary care encounters (stop code 323). 

38 

Women Veterans Health 


Strategic Health Care Group
 

www.womenshealth.va.gov
 

Department of Veterans Affairs 

Veterans Health Administration 

810 Vermont Avenue, NW 

Washington, DC 20420 

December 2010