VA Women’s Health Care Delivery & Quality: Effectively Integrating Women Veterans into the Mindset of QUERI Stakehol

1. Center for the Study of Healthcare Provider Behavior VA Women’s Health Care Delivery & Quality:Effectively Integrating Women Veterans into the Mindset of QUERI Stakeholders National VA QUERI Meeting Phoenix, AZ  December 11, 2008

2. Workshop Leaders • Patricia Hayes, PhD • Chief Consultant, Women Veterans Health Strategic Healthcare Group • Steve Wright, PhD • Director of Epidemiology, VA Office of Quality & Performance (OQP) • Donna Washington, MD, MPH • Core Investigator and Staff Physician, VA Greater Los Angeles Healthcare System • Becky Yano, PhD, MSPH • Research Career Scientist, VA Greater Los Angeles HSR&D Center of Excellence

3. Workshop Objectives • Educate QUERI researchers and system partners about what is known about: • how women veterans use the VA, • their physical and mental health burdens, and • how VA care is organized to meet their needs • Highlight the WVHSHG’s strategic plans and needs around women veterans’ QI • Report on gender disparities in VA performance measures • Discuss approaches to ensuring representation of women veterans in QUERI programs

5. Center for the Study of Healthcare Provider Behavior Effectively Integrating Women Veterans into the Mindset of QUERI Stakeholders:How Do We Get From Here to There?Becky Yano, PhD, MSPH National VA QUERI Meeting Phoenix, AZ  December 11, 2008

6. Perceived Barriers to Integrating Women into QUERI Efforts • Too few to effectively integrate • Small sample sizes  not enough cases to analyze subgroups  end up wasting data • Difficult to recruit  different utilization patterns (where are they?) • Primary care based recruitment may miss them • Women’s clinics highly variable  some comprehensive and some paps only

7. Perceived Barriers to Integrating Women into QUERI Efforts • Greater dual use among women vets? • Different insurance status  more likely to use VA and non-VA than male vets • Higher use of fee basis and contract care  incomplete portrait of their care • Are they so different that your intervention doesn’t map to their needs?

8. Spinal Cord Injury Women Veterans HIV/Hep C Mental Health Diabetes • What is the prevalence by gender • outside the VA? • Does age, health, dxs influence • likelihood WVs are part of registry? • Would your interventions vary if • women were explicitly included? Stroke Ischemic HD Congestive HF Substance Use Disorders Polytrauma

9. Adapting QUERI Studies/Trials for Women Veterans • Mental Health QUERI • Women’s mental health clinics (RRP) • Women’s Health TIDES? • HIV/Hepatitis QUERI • HIV screening in women’s clinics? • Spinal Cord Injury QUERI

10. Adapting QUERI Studies/Trials for Women Veterans • Congestive Heart Failure QUERI • Diabetes QUERI • Ischemic Heart Disease QUERI

11. Adapting QUERI Studies/Trials for Women Veterans • Stroke QUERI • Substance Use Disorders QUERI • Polytrauma QUERI

12. Gender Disparities • Any evidence of gender disparities in each QUERI? • VA EPRP measures suggest work needed in • Diabetes QUERI • Mental Health QUERI • Others? • Other evidence of gender differences in access to, use, costs, quality of care?

13. Hypotheses about Differences • Why do you think we are seeing these differences in VA quality of care for women?

14. Going Beyond QUERI Centers • How to accelerate building evidence base and implementing QI interventions? • Top WH conditions differ from those of men • Can QUERI Centers and/or individual researchers take these issues on? • Ex: Partner Mental Health QUERI x National Centers for PTSD  QI for PTSD/MST for WVs • Ex: Less breast conserving surgery in VA vs. private sector  how apply QUERI methods to investigate, identify determinants and remedy?

15. Technical Support • What kind of information/support do you need in order to integrate women veterans into your portfolio? • Organizational variations in care? • Patterns of utilization? • Local women’s health program manager contacts? • Clinical, health status, demographic data?

16. Sources of Collaboration to Leverage QUERI Efforts • Women Veterans Health Strategic Healthcare Group as partner • Women Veteran Program Managers (dedicated FTEE/VA facility with WH expertise) • Women’s Health Fellowship Program sites • Women’s Health Clinical Centers of Excellence (e.g., Palo Alto) • Consortium of VA-based women’s health researchers

17. VA Women’s Health Researchers 2 new VAMC’s (90,000 PC Patients) 9 New VAMC’s (90,000 PC Patients) 2 New VAMC’s (40,000 PC Patients) 2 New VAMC’s (40,000 PC Patients) ReTIDES Spread Active VA Women’s Health Researchers BRADLEY HAMMOND KLUTE VA Puget Sound HASKELL BRANDT JUSTICE MADDOX VA West Haven MURDOCH POLUSNY ENSRUD VA Minneapolis SCHNURR VA White River Junction BRADLEY VA Roseburg 8 DCMs KREIN VA Ann Arbor SHIPHERD RESICK VOGT SEAVER VA Boston KRESSIN VA Bedford KIMERLING National Center for PTSD SADLER VA Iowa City 2 DCMs SAMBAMOORTHI TSENG, POGACH VA East Orange WEAVER LA VELA Hines VA WEISMAN Penn State FRAYNE TIMKO VA Palo Alto 4 DCMs McNEIL BORRERA VA Pittsburgh BASTIAN CHIREAU VA Durham YEE VA Albuquerque WASHINGTON BEAN-MAYBERRY YANO VA Greater LA MAGRUDER VA Charleston VERNON Univ Texas BOOTH VA Little Rock SURIS Dallas VA 2 DCMs LUTHER VA Gainesville

18. Questions ?

19. More VA Women’s Health Care Research Has Been Funded • Impact of practice structure on quality of care for women veterans(Yano) • Gender equity in VA quality (Bean-Mayberry) • Chronic physical and mental illness care in women veterans(Sambamoorthi) • Quality of breast cancer care in VA(Luther) • Fragmentation of care and unmet health care needs(Washington) • Determinants of changes in how VA women’s health care is organized(Yano)

20. More VA Women’s Health Care Research on OIF/OEF Funded • Sexual violence and gynecologic health(Sadler) • Evaluation of MST screening/treatment(Kimerling) • MST effects on PTSD and behavior among Marines(Shipherd) • Physical and sexual assault in deployed women: risks, outcomes, services(Sadler) • Stigma, gender and other barriers to VA care (Vogt)

21. Brief Research Highlights • New systematic literature review funded • Focus on women veterans’ research has created a virtual “explosion” of new studies and new published results • VA HSR&D funded an update of the review done in 2004 (published in Journal of General Internal Medicine in 2006) • Bevanne Bean-Mayberry, MD (PI) (GLA)

22. New Women Veterans Cohort Study • Women’s Healthcare Evaluation of Resource Utilization and Outcomes Assessment (HERA) • OIF/OEF women veterans with matched men • West Haven, CT and Indianapolis, IN initial cohorts • Obtained additional resources to add other sites (e.g., Los Angeles, Tampa) • Assess health care utilization, costs and satisfaction 2 years after discharge and after 2-year coverage ends • Compare diagnosis/treatment of stress associated conditions during 2-year coverage period Source: Brandt, Haskell, Justice et al (2008-2011) VA West Haven

23. National Survey of Women Veterans • New national survey funded by WVHSHG • Objectives of new national survey are to: • Identify current demographics, health care needs, and VA experiences of women veterans • Determine how health care needs and barriers to VA health care use differ among women veterans of different periods of military services (e.g., OEF/OIF vs. earlier periods) • Assess women veterans’ preferences for and perceived value of different types of VA interventions to improve access and quality • From 2,500 to 3,200 will be surveyed across US • Equal numbers of VA users and non-users Source: Washington (2007-09) (GLA)

24. National Survey of Veterans • Public law dictates decennial survey of veterans nationwide • Contract for 2010 survey funded to Westat • Funded to oversample women veterans • Focus on outreach/education and issues of employability/transitions

25. Evolution of VA Women’s Health Clinics Legislated WH service expansion WHC mandate to “preferred” GAO Report Comprehensive Women’s Health Centers Funded WV Health Program Act (P.L. 102-585) GAO Report GAO Report OEF* Gulf War OIF* Source: Yano EM, et al. Diffusion of VA women’s health clinics. Women’s Health Issues. 2006.