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Achieving Equitable High-Quality Care for Women Veterans

Women have been an extreme numerical minority in VA settings for many years, settings that once reflected the historical 2 percent cap on their participation in the military. These settings offered limited acknowledgment of women veterans' contributions and the risks they faced while serving their country.¹ As a consequence, few VA providers have much experience seeing women patients, and few women veterans know much about their veteran benefits; fewer still are aware of the availability of women's health services in the VA.²

Among those women who use VA care, many now have the option of being seen in women's health clinics, their growth rate roughly paralleling increases in women veteran caseloads. However, recent evidence suggests that, on average, these clinics are open roughly halftime-reducing access-and that over 40 percent of these clinics focus on genderspecific exams only. While comprehensive women's primary care clinics exist, they are the exception rather than the rule. As Dr. Hayes points out, however, changes are taking place at an unprecedented rate, and VA researchers are in a unique position to support and inform the transitions ahead.

History of VA Women's Health Research

VA women's health research has had a relatively brief but highly dynamic and productive evolution in recent years. In 2003, in response to inquiries from policymakers, the VA Office of Research & Development (ORD) sponsored establishment of a VA women's health research agenda. A national planning group combined an appraisal of VA's research portfolio with a systematic literature review and secondary analyses of existing databases to serve as the foundation for a national consensus development conference designed to set evidence-based research priorities.³ Subsequently, following an unexpectedly high number of submissions,HSR&D funded a special issue of the Journal of General Internal Medicine, which came out in 2006, that focused on women veterans' health and health care. In the intervening years, the virtual explosion of women veterans' related research literature has led to the funding by VA HSR&D's Evidence Synthesis Program (ESP) of an updated systematic review, which is now underway.

VA HSR&D Service has explicitly made women's health services research a priority solicitation area for over a decade. While only a handful of women's health projects were funded in the early years, this changed significantly following the establishment of the VA women's health research agenda. VA HSR&D has funded a broad range of research related to this agenda, including: assessing women veterans' chronic physical and mental illnesses (Sambamoorthi & Findlay, East Orange VA); their unmet health care needs and fragmentation (Washington, West Los Angeles VA); the quality of breast cancer care received in VA settings (Luther, Gainesville VA); determinants of changes in how VA care is organized (Yano, Sepulveda VA); resource use and outcomes among OEF/OIF women veterans compared to men (Brandt, Haskell & Justice, West Haven VA); sexual violence and gynecologic health (Sadler, Iowa City VA); evaluation of MST screening and treatment (Kimerling, Palo Alto VA); MST effects of PTSD and behavior among women Marines (Shipherd, Boston VA); physical and sexual assault among deployed women (Sadler, Iowa City VA); and, stigma and barriers to care (Vogt, Boston VA), among others.

Spotlight on VA Women's Health Services Research

VA women's health services research now has the direct attention of national leaders in VA Central Office, and beyond. While the spotlight can be bright, this attention brings with it an unprecedented opportunity to conduct research that is highly policy relevant to a waiting audience. VA managers and clinicians are facing enormous challenges ahead, as the numbers of women veterans double. Almost all of the women veterans' research literature reflects descriptive or observational studies, leaving an enormous hole-and opportunity-for designing and conducting studies of quality improvement interventions that can help improve women's health care and address gender disparities.

Interventions for promoting provider skills, proficiency, and comfort in treating women veterans are needed, as are interventions for improving women veterans' knowledge and awareness of their VA benefits, and their entree to VA care. Given the substantial amount of care that women veterans receive in the community, via fee basis and contract care, studies are needed that evaluate the quality of care delivered. Coordination of care among multiple providers, especially for women with comorbid mental health conditions, is another important research area.

While the VA has mandated inclusion of women in all VA studies since 1983, I believe that most "non-compliance" is unlikely purposeful but instead a function of the difficulties inherent in recruiting available women in sufficient numbers. Creation of a women veterans' practice-based research network would help remedy this structural limitation by setting up the infrastructure for trials in VA medical centers with larger volumes of female patients. As members of the VA research community, it is incumbent on all of us to be mindful of not only the requirements but also the value of including women veterans in our research.

The time is ripe for advancing VA women's health research in ways that we did not even envision during the agenda-setting process a few short years ago. I invite you to join the growing consortium of researchers working in this arena, and challenge you to consider innovative ways to integrate women veterans into your current research.

References

1. Murdoch M, et al. Women and War:What Physicians Should Know. Journal of General Internal Medicine 2006; 21(Suppl 3):S5-10.
2. Washington DL, et al. To Use or Not to Use--Women Veterans' Choices About VA Health Care Use. Journal of General Internal Medicine 2006; 21(Suppl 3):S11-18.
3. Yano EM, et al. Toward a VA Women's Health Research Agenda: Setting Evidence-Based Priorities to Improve the Health and Health Care of Women Veterans. Journal of General Internal Medicine 2006; 21(Suppl 3):S93-101.