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Response to Commentary

The Critical Role VA Health Services Research Plays in Partnership with Health System Leaders to Accelerate Evidence-based Advances in Care for Women Veterans

Drs. Hayes and Haskell note in their Commentary that the rapid increase of women Veterans among VA users escalates demand for a stronger evidence base to guide their care. Fortunately, VA HSR&D has been a leader in women Veterans’ research, addressing critical knowledge gaps. Aligned with VA’s Office of Women’s Health (OWH) and other health system partners since its inception in 2010, the VA Women’s Health Research Network (WHRN) is among HSR&D’s initiatives to transform VA’s capacity to: 1) reduce gender disparities in health and healthcare; and 2) use research to increase delivery of evidence-based care tailored to women Veterans’ needs. To that end, WHRN has three arms: a Research Consortium, a Women’s Health Practice-Based Research Network (WH-PBRN), and a Multilevel Stakeholder Engagement Team.

From the outset, the Consortium focused on building awareness and capacity through women Veteran-focused education and training (over 100 national cyber-seminars to date); technical support (consults, pre-submission scans of grant proposals); mentorship (national cadre of mentors, career development support in key areas such as intimate partner violence, cardiovascular risk reduction, reproductive healthcare, and more); collaborative research development (national work groups supporting scores of women’s health grant proposal submissions); dissemination (eight VA-funded journal supplements, topical lay-language research “snapshots,” conferences); and enhanced research-operations partnerships to accelerate translation of research into evidence-based practice and policy. By 2014, WHRN convened a National VA Women’s Health Services Research Conference, bringing together national VA policy leaders and women’s health researchers, as well as leaders from the Institute of Medicine, U.S. Departments of Defense, Health & Human Services (including NIH), Justice, and Labor, among others. Participants learned about the state of the science and reached consensus on an HSR&D-focused research agenda, which expanded strategic planning in new priority areas, including access/rural health, primary care/prevention, mental health, post-deployment health, complex chronic conditions/aging, and reproductive health. Meaningful partnerships with operations leaders were central to these efforts, with foundational, bidirectional expectations that VA priorities would drive VA women’s health research, and VA women’s health research would inform VA practice and policy. ¹

With this foundation, we turned our attention to driving the implementation of women’s health research – rare prior to WHRN – to accelerate impacts. First, we focused on the portfolio of work in the HSR&D-funded Women Veterans’ Healthcare CREATE Initiative mentioned by Drs. Hayes and Haskell, our primary CREATE partners, leveraging the WH-PBRN to facilitate recruitment of sites, providers/staff, and women Veterans. Capitalizing upon the WH-PBRN as a testing ground for implementing and spreading evidence-based practices, one of the CREATE trials tested an evidence-based quality improvement (EBQI) approach to gender-tailoring primary care. It demonstrated substantial gains in access to women’s primary care providers, trauma-sensitive care, and cancer screening and follow-up, improved PACT team function and providers’ gender sensitivity, and lowered burnout. WHRN extended this strategy through the WH-PBRN’s deployment of regional and national Quality Improvement Collaboratives, leveraging trial evidence in naturalistic settings, while studying how to spread evidence more effectively and efficiently. OWH has since adopted EBQI nationally.

Having grown from four to 76 VA facilities nationally, the WH-PBRN now covers the majority of women Veterans seen in VA. Investigators wanting to enhance representation of women Veterans or VA women’s health providers in their studies can capitalize on site leads’ local connections with patients, clinicians, staff, managers, and leaders. Nearly 100 multi-site projects have benefited from this national network, selecting sites that meet their study needs. Given the fundamentally partnered nature of our work, it is no surprise that studies conducted in the WH-PBRN have examined many of the key topics highlighted by Drs. Hayes and Haskell, such as breast cancer screening, pregnancy, contraception, menopause, heart disease, suicide prevention, PTSD, military sexual trauma, and community care. Expertise in recruiting women Veterans into VA research also led to funding from the VA Cooperative Studies Program (CSP) to evaluate how to optimize women’s enrollment in a comparative effectiveness trial of PTSD treatment (CSP #591), building a bridge between clinical sciences and HSR&D.

As WHRN evolved, we began testing strategies for supporting VA as a learning healthcare system, increasing employee engagement in research-clinical partnerships capable of generating and acting on research evidence to respond to priority needs.² For example, given that the rate of suicide among women Veterans is nearly double that of civilian women, WHRN’s Consortium launched a women Veterans’ suicide research group, partnered with VA’s Office of Mental Health & Suicide Prevention, yielding a portfolio of partner-responsive work including a national research agenda, a published journal supplement, and six new studies in record time. In parallel, the WH-PBRN designed novel practice scans of member sites to learn how care is organized or delivered. The WH-PBRN can also rapidly gauge women Veterans’ care preferences and experiences via short anonymous in-clinic surveys, feeding results back to participating sites and health system leaders; over 50 VAs and thousands of women Veterans have participated in at least one of these Veteran Feedback Projects, delivering actionable data in weeks instead of years. For example, in response to finding that one in four women Veteran primary care users experienced stranger harassment in VA, OWH requested annual Veteran Feedback Projects to monitor the effectiveness of VA’s efforts to end harassment. Results are also shared with participating VAs where they are used to impact local culture change efforts. They are also now reported to Congress as required by the Deborah Sampson Act.

Throughout this journey, we increasingly recognized the vital importance of integrating a multilevel stakeholder engagement focus to our work. Based on interviews with over 80 VA leaders, providers, researchers, and women Veterans, WHRN has tailored and disseminated new strategies and tools for vetting research plans and products with the many stakeholders in VA care delivery, including women Veterans. WHRN launched the Women’s Improvement Network to directly engage a diverse national panel of women Veteran VA users in the design, planning, execution, review, and dissemination of VA women’s health research.³

We have also helped VA Central Office partner with VA researchers to complete legislatively mandated studies. For the National Defense Authorization Act, VA researchers at Salt Lake City examined post-9/11 women Veterans’ unemployment patterns and drivers. For the Deborah Sampson Act, VA researchers at the Connecticut VA engaged researchers from across the country to contribute data to better estimate the prevalence of intimate partner violence among Veterans, while researchers at the Durham and Greater Los Angeles VAs evaluated Veterans’ childcare needs and experiences to inform design of the Act’s mandated VA-wide childcare arrangements. These efforts were from this year alone.

These accomplishments are the product of the engagement and labors of a highly collaborative national community of research and clinical colleagues with local, regional, and national operations partners collectively dedicated to using research to better the lives of women Veterans. This work would not have been possible without the service-mindedness of women Veterans themselves who step up not only as research participants but also engaged research partners. Through the power of partnership, we are making critical progress toward ensuring women Veterans receive the best evidence-based quality care available.

References

1. Yano EM, Tomoyasu N. “Accelerating Generation and Impacts of Research Evidence to Improve Women Veterans’ Health and Health Care,” Journal of General Internal Medicine 2022; 37(Suppl 3):668-70.
2. Golden RE, et al. for the WH-PBRN Complementary and Integrative Health Writing Group. “Promoting Learning Health System Feedback Loops: Experience with a VA practice-based Research Network Card Study,” Healthcare (Amsterdam) 2021; 8 Suppl 1:1-8.
3. Chrystal JG, et al. “Increasing Engagement of Women Veterans in Health Research,” Journal of General Internal Medicine 2022; 37(Suppl 1):42-9.