National Women's Health Week
May 14-20, 2017 is National Women's Health Week. Currently, women are entering the military in record numbers and comprise 20% of new recruits, and it is estimated that by next year, women will make up 10% of the Veteran population. VA supports a comprehensive women's health research agenda that includes significant contributions from HSR&D. For example, HSR&D funded the Women's Health Research Network, which is composed of two partners—the Women's Health Research Consortium, and the Women's Health Practice-Based Research Network. In addition, HSR&D's Women Veterans Healthcare CREATE (Collaborative Research to Enhance and Advance Transformation and Excellence) initiative conducts research to examine the essential factors that facilitate (or slow) the pace, effectiveness, and outcomes of delivery of comprehensive care for women Veterans. This CREATE works closely with several operational partners, such as the Office of Women's Health Services, the Office of Mental Health Services, the Office of Patient Care Services (PCS), the Office of Specialty Care Services (SCS), and VHA's Office of Community Care.
Following are descriptions and findings from several research projects conducted by HSR&D and QUERI (Quality Enhancement Research Initiative) investigators on issues critical to improving the health and care of women Veterans.
Evaluating Outsourced Care for Women Veterans
While the number of women Veterans utilizing VA care is rising, many specialized, gender-specific services (e.g. mammography and prenatal care) are not widely available within the VA healthcare system. In these instances, federal law enables VA to pay for Veterans' care at outside facilities. This ongoing study examines providers' and fee-basis managers' strategies for the provision, coordination, and oversight of outsourced care. Investigators also are assessing the perceptions and experiences of women Veterans with non-VA care. Follow-up of abnormal mammograms is used as a case example for evaluating gender-specific non-VA care.
Study investigators used the Women's Health Evaluation Initiative Database (WHEI) to ascertain the top 24 VA sites nationally for non-VA care referrals for women Veterans - and to identify women Veterans from each of those facilities that received non-VA care from FY2010-FY2012. In addition, women's health providers and fee-basis managers from the 24 facilities were interviewed to understand their perceptions and experiences with non-VA care. Investigators also conducted a retrospective electronic medical chart review to identify women (ages 40-74) at 8 sites with either non-VA or in-house mammograms in FY12. They then evaluated whether the results of mammograms were appropriately acknowledged in the patient's medical record, and whether abnormal mammograms received appropriate and timely follow-up. Abnormal mammogram results were defined by the existing Breast Imaging Reporting and Data System Atlas (BI-RADS) scoring system, using BI-RADS categories of 0 (indeterminate), 3 (probably benign), 4 (suspicious for cancer), and 5 (highly suspicious for cancer). Thus far, findings show that 6,800 completed mammograms were requested in FY2012: 643 (10%) mammograms were missing BI-RADS scoring from administrative data, in addition to 848 (13%) with a BI-RADS score of 0, 48 (0.7 %) with a score of 3, and 17 (0.3%) with scores of 4 or 5.
Implications: Given that the use of non-VA care is increasing within the VA system and due to the Veterans Choice Program, understanding the provision, coordination, and perceived quality of this type of care is of utmost importance as VA continues to understand how to provide the best comprehensive healthcare for women Veterans.
Mattocks K, Mengeling M, Sadler A, et al. The Veterans Choice Act: A qualitative examination of rapid policy implementation in the Department of Veterans Affairs. Medical Care. January 31, 2017; Epub ahead of print.
VA Maternity Care Coordination
Recent evidence suggests the number of women Veterans delivering babies using VA maternity benefits has nearly doubled in the past five years. Moreover, because nearly all maternity care is provided by community obstetrical providers through the non-VA care program, virtually nothing is known about how women Veterans access and use maternity care services, how their maternity care is coordinated, or how ongoing VA care (e.g., primary care, specialty care, and mental healthcare) is managed during and after pregnancy. Therefore, this ongoing study seeks to characterize women Veterans' maternity care experiences with accessing this care, including any barriers and facilitators they experience in care coordination across VA and non-VA facilities. Investigators recruited pregnant Veterans from 13 VA facilities across the country, conducting surveys at approximately 20 weeks of pregnancy and again at 12 weeks postpartum. Information is being analyzed regarding perceptions of maternity care coordination, as well as pregnancy experiences, co-existing physical and mental health conditions during pregnancy, social support, and postpartum health of both mother and baby. To date, 231 pregnant Veterans have enrolled in the study and completed the pregnancy interview, and 125 of these women have completed the post-partum interview. Thus far, findings show:
- Pregnant Veterans experience substantial mental health burdens during pregnancy, with nearly half of all pregnant Veterans having a diagnosis of depression or PTSD. However, few women seek mental healthcare during their pregnancy, due either to the inability to find a community mental health provider or perceptions that VA mental health care is not available during their pregnancy.
- Forty-nine percent of women had a diagnosis of depression, while 34% had a diagnosis of PTSD. However, fewer than 30% of women had plans to continue to see their VA mental health provider during pregnancy despite diagnosis of depression or PTSD.
- Thirty-two percent of women Veterans were unable to access prenatal care as soon as they would have liked due to an inability to find a non-VA provider willing to accept VA maternity benefits.
- Following delivery, only 8% of women reported receiving mental healthcare during pregnancy from either a VA or community provider.
Implications: Care coordination between VA and non-VA providers for pregnant Veterans is important given the burden of depression and PTSD during pregnancy. VA must prioritize care coordination strategies to ensure that Veterans are receiving comprehensive care across VA and non-VA health care systems.
Sexual Trauma during Military Increases Risk of Subsequent Suicide
Veterans are at increased risk for suicide relative to the general U.S. population, prompting a focus on the conditions and experiences that account for this excess risk. While mental health conditions (i.e., PTSD, schizophrenia, and substance use disorder) are reliably associated with suicide risk, the risks posed by deployment to Iraq or Afghanistan are less clear. Moreover, little is known about other military experiences that may increase risk for suicide, such as military sexual trauma (MST). This was the first large-scale, population-based study of sexual trauma and suicide mortality that examined risks associated with MST among both male and female Veterans receiving VA care. Using VA data, investigators identified more than six million male Veterans and 363,680 female Veterans who received VA outpatient services between FY2007 and FY2011, and who were screened for MST. Findings show:
- Overall, 1% of men, and 21% of women Veterans in this study reported MST when screened. Of the Veterans in this study cohort, 9,017 completed suicide during the follow-up period. Both women and men who reported MST had an increased risk of suicide, even after adjusting for other risk factors, including mental health conditions, medical morbidity, and demographic characteristics.
- Effects were notable for women Veterans in particular: the increased risk associated with MST could contribute to between 10% and 20% of all suicides in women Veterans receiving VA healthcare.
Implications: In FY2013, VA provided specialized MST-related mental healthcare to 59% of women Veterans and 44% of male Veterans who reported MST, representing potential opportunities for prevention interventions for those at increased risk of suicide. This is the first study to document that sexual trauma during military service increases subsequent risk of suicide among Veterans. Findings have informed VA approaches to both MST services and suicide prevention.
Kimerling R, Makin-Byrd K, Louzon S, et al. Military sexual trauma and suicide mortality. American Journal of Preventive Medicine. June 2016;50(6):684-691.
High Prevalence of Intimate Partner Violence among Older Women Veterans
The US Preventive Services Task Force recommends screening women of childbearing age for current intimate partner violence (IPV) experiences, as early intervention can mitigate the health impact of IPV. VA is implementing a national IPV screening program that is integrated with a broad range of healthcare programs across the system. This retrospective cohort study sought to identify the prevalence of past-year IPV among women Veterans using VA primary care, and to document associated demographic, military, and primary care characteristics. Investigators used data from the WOMAN (Women's Overall Mental Health Assessment of Needs) survey - a telephone survey conducted in 2012 with a national sample of 6,046 women Veterans. In addition, study investigators used self-report and VA data to assess primary care use (VA and non-VA). Findings show:
- The prevalence of past-year IPV among women Veterans who used VA primary care services was 19%, with higher rates (22% to 26%) among women up to age 55. Most women (77%) who experienced IPV identified a VA provider as their usual healthcare provider.
- Women who were not employed full-time, received public assistance, had been homeless within the past year, or had an annual income of less than $25,000 were more likely to have experienced IPV.
- Age-adjusted military correlates included service during Vietnam to post-Vietnam eras, less than 10 years of service, and experiences of military sexual trauma (MST).
Implications: The high prevalence of past-year IPV among women beyond childbearing years, the majority of whom primarily rely on VA as a source of healthcare, reinforces the importance of screening all women for IPV in VA primary care settings.
Kimerling R, Iverson K, Dichter M, et al. Prevalence of intimate partner violence among women Veterans who utilize Veterans Health Administration primary care. Journal of General Internal Medicine. August 31, 2016;31(8):888-894.
Attrition of Women Veterans New to VA
Among women new to VA healthcare in 2006, earlier work showed that 30% did not return in the subsequent two years. This rate of attrition was of major concern, especially with women continuing to be the fastest growing segment of new VA patients, and with access to high-quality, comprehensive women's health (WH) care among the top VA priorities. Therefore, this ongoing study of women Veterans new to VA healthcare aims to:
- Identify predictors of attrition (i.e., patient experiences with VA care, VA organizational factors, community healthcare resources, and patient factors);
- Determine whether patterns of attrition are changing over time;
- Understand perspectives of women Veterans (i.e., what factors led them to leave or to stay); and
- Explore plans for future VA use among new women Veteran patients currently using VA.
Early findings from this study show:
- Among women Veterans who used VA outpatient care in FY2009, those who lived farther from a VA facility were more likely to leave VA care, as were younger women, women with lower service-connected disability or with fewer medical conditions, and women who used VA less frequently.
- New women patients had nearly four-fold higher odds of leaving VA than established women patients. Preliminary analyses examining women Veteran primary care patients who were new to VHA in FY2011 revealed that those who saw a Designated Women's Health Primary Care Provider had lower odds of leaving VA than did women who saw other primary care providers.
Impact: As VA seeks to make its services welcoming and accessible to women Veterans and sensitive to their healthcare needs, those lost to the system represent a group requiring special targeting. Their experiences may provide clues about how to optimize women's healthcare in VA settings, such as by ensuring that women have access to Designated Women's Health Primary Care Providers.
Friedman S, Frayne S, Berg E, et al. Travel time and attrition from VHA care among women Veterans: How far is too far? Medical Care. April 1, 2015;53(4 Suppl 1):S15-22.
Women Veterans' Health Care. Find out how to apply for VA healthcare for women.
Women's Health Research. More information about HSR&D research on women Veterans' health and care, including a research agenda and systematic reviews.
VA's Center for Women Veterans. Highlights opportunities and resources for women Veterans.