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2023 HSR&D/QUERI National Conference Abstract

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1094 — Cardiovascular Disease in Women Veterans: Implementing a Toolkit in Primary Care Increased Participation in Behavioral Change Programs

Lead/Presenter: Melissa Farmer,  COIN - Los Angeles
All Authors: Farmer MM (VA Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, CA), Hamilton, A (VA Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, CA; UCLA David Geffen School of Medicine, Los Angeles, CA) Finley, E (Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, CA ; Long School of Medicine, University of Texas Health Science Center San Antonio, San Antonio, TX) Lee, Martin (Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, CA) Huynh, AK (Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, CA) Chanfreau, C (VA Informatics and Computing Infrastructure (VINCI), VA Salt Lake City Healthcare System, Salt Lake City, UT) Than, Claire (Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, CA) Brunner, J (Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, CA) Schweizer, CA (Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, CA) Moin, T (Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, CA; UCLA David Geffen School of Medicine, Los Angeles, CA) Bean-Mayberry B (Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, CA; UCLA David Geffen School of Medicine, Los Angeles, CA)

Objectives:
Cardiovascular (CV) disease is the number one cause of death for women in the US, yet many women have limited understanding of their CV-related morbidity and mortality risk. Women have more difficulty managing CV risk factors and have higher obesity and inactivity rates compared to men. Women Veterans also have higher rates of mental health conditions than men Veterans, which compound their risk and makes CV risk reduction a critical VA women’s health priority. The EMPOWER QUERI implemented and evaluated a CV toolkit targeting women Veterans in primary care, with the goals of increasing CV risk identification, enhancing patient/provider communication about risk, and increasing women’s participation in relevant behavior change programs.

Methods:
In partnership with the VA Office of Women’s Health and National Center for Health Promotion and Disease Prevention (NCP), we developed a CV toolkit that included three components: patient CV self-screener; provider risk template in the electronic medical record; and a facilitated goal-setting group tailored for women developed by NCP (Gateway to Healthy Living). Using a non-randomized stepped wedge design, we evaluated the effect of toolkit implementation on participation in behavior change programs that target CV risk reduction: 1) MOVE! weight loss program, and 2) health promotion and disease prevention (HPDP) programs (coaching, facilitated groups, etc.) and complementary integrative health (CIH) services (yoga, Tai Chi, meditation, etc.). Patient characteristics and utilization were extracted from administrative data. We utilized a three-level (patient, site, time) non-linear fixed effect model, and estimated each model stratified by age (65 and older and less than 65).

Results:
Five VA health clinics implemented the CV toolkit between 6/2017-3/2020; two sites shortened implementation due to COVID-19. Among women with at least one primary care visit during this time (n = 6009), the mean age was 45 years, 38% were white, 31% black and 17% Hispanic, and CV risk factors were widespread: 30% were overweight, 38% obese, 30% had high cholesterol, and 26% had hypertension. Thirty-five percent had depression and 30% had PTSD documented in the last two years. For women 65 years and older (n = 540), active toolkit implementation resulted in increased odds of MOVE! participation (OR = 1.089; 95%CI:1.030,1.152) and no differences for HPDP/CIH participation (OR = 0.999; 95%CI:0.976-1.022) compared to when the toolkit was not active either within or between sites. Women younger than 65 (n = 5469) had increased odds (OR = 1.012; 95%CI:1.002-1.020) of using HPDP/CIH services during active toolkit implementation, with a positive trend in increased MOVE! participation (OR: 1.57; CI = 0.959-1.165).

Implications:
The CV toolkit intervention was effective in increasing participation in behavior change programs even with shortened implementation periods due to COVID-19. For women age 65 and older, the intervention increased odds of participation in VA’s traditional weight reduction program, whereas for younger women, it was effective for newer programs including CIH services.

Impacts:
Successful toolkit implementation showed that facilitating communication between women Veterans and their providers increased participation in behavior change programs. The variation in program participation by age group suggests that VA program variety may be key to facilitating CV targeted behavior change for women across the lifespan.