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2019 HSR&D/QUERI National Conference Abstract

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1113 — Can Non-VA Community Care Meet the Gaps in VA Gynecology Care?

Lead/Presenter: Sarah Friedman,  COIN - Palo Alto
All Authors: Friedman SA (Fielding School of Public Health, UCLA; Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA ), Mattocks K (VA Central Western Massachusetts Healthcare System; University of Massachusetts, Medical School, Worcester MA), Phibbs CS (VA HSR&D Center for Innovation to Implementation, VA Palo Alto Health Care System; Stanford University School of Medicine, Palo Alto CA) Shaw JG (VA HSR&D Center for Innovation to Implementation, VA Palo Alto Health Care System; Stanford University School of Medicine, Palo Alto CA) Yano EM (VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles; Office of Health Equity-QUERI PEI; UCLA) Washington DL (OHE-QUERI PEI; VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles; UCLA) Saechao F (VA HSR&D Center for Innovation to Implementation, VA Palo Alto Health Care System) Hamilton AB (VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles; UCLA) Berg E (VA HSR&D Center for Innovation to Implementation, VA Palo Alto Health Care System) Frayne SM (A HSR&D Center for Innovation to Implementation, VA Palo Alto Health Care System; Stanford University School of Medicine)

Objectives:
VA refers patients to community providers for specialty services not available on-site. However, community-level specialist shortages could impede these Veterans' access to care. We characterized gynecologist availability within local VAs, and compared geographic availability of community-based gynecology care for women with and without a gynecologist at their local VA.

Methods:
We examined a fiscal year 2011 cohort of women Veterans new to VA, identified from VA administrative data. Availability of specialty gynecology care at or near a woman's home site (VA Medical Center/Community-Based Outpatient Clinic) came from Women's Health Services' national WATCH organizational survey. Applying ACOG's guidance on gynecologist-to-population ratios, we classified counties with < 1 gynecologist/10,000 women (per the Area Health Resource File) as "low supply" counties.

Results:
Among 19,298 women Veterans, a total of 77% had a VA gynecologist, either at their home site (59%) or another VA site < 50 miles from that site (18%). However, for 23% there was no VA gynecologist within 50 miles: among them, over half also did not have a community-based gynecologist within 50 miles. Women without VA gynecology within 50 miles were more likely than other Veterans to live in "low supply" counties (25% versus 15%, p < 0.0001). These differences existed across race/ethnicity and urban/rural residence nationwide.

Implications:
Women Veterans whose local VA network lacked specialty gynecology care were also more likely to have limited options for non-VA sources of gynecology care. Many of these women would likely have been obliged to travel more than 50 miles to access gynecological care (whether VA or community-based), given scarce community-based options within their home county.

Impacts:
The Veterans Choice Act and now MISSION Act entitle VA patients lacking timely or geographically proximate VA care to access non-VA providers. However, relying solely on such legislative efforts may not suffice to alleviate access issues because, as demonstrated with gynecology services, regional gaps in VA specialty care can correlate with similar under-supply in the surrounding community. While VA has expanded on-site gynecology in recent years, evaluation of transportation options, staffing models (e.g., VA-based floating gynecologists), or tele-gynecology may offer solutions for low-supply regions.