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IIR 04-036 – HSR&D Study

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IIR 04-036
Impact of Practice Structure on the Quality of Care for Women Veterans
Elizabeth M Yano PhD MSPH
VA Greater Los Angeles Healthcare System, Sepulveda, CA
Sepulveda, CA
Funding Period: April 2005 - March 2007

BACKGROUND/RATIONALE:
Women veterans are among the fastest growing segment of new VA users, yet their growing presence has highlighted gaps in VA access and quality. As a result, Congressional eligibility reforms profoundly changed the array of VA health care services to be made available to women veterans. Considerable debate remains about how best to organize VA care for women veterans to address legislative mandates of equitable access to a wide array of services. While VA facilities have adopted a variety of clinic models for delivering women's health care, none dominates, and the quality and costs associated varying delivery models established to meet their needs is currently unknown.

OBJECTIVE(S):
Our objective was to inform practice and policy options for optimal delivery of VA care to women veterans by evaluating the quality of care and costs associated with the prevailing delivery models in VHA.

METHODS:
We undertook four main activities: (1) an expert panel to develop an evidence-based organizational taxonomy of delivery models for women veterans; (2) design and administration of a new national VHA Survey of Women Veterans Health Programs and Practices; (3) statistical analyses of merged organizational and performance data to evaluate quality of care associated with different VA care models; and (4) an exploration of costs associated with care model variants recommended by VHA policy. We use modified Delphi consensus development techniques for convening the expert panel comprised of representatives of the array of VA delivery models to arrive at essential management and clinical features needed to deliver high quality care to women veterans. We applied the resulting organizational taxonomy to standard survey development and field techniques for designing and administering multi-level survey modules targeting VISN, VAMC and geographically distinct practices. Concurrently, we combined a prior all-VA organizational survey with successive years of data from the VA Survey of Healthcare Experiences for Patients (SHEPs) and External Peer Review Program (EPRP), in addition to Austin data for patient-level covariates and Area Resource File (ARF) data for contextual measures. We used the VA Decision Support System (DSS) to estimate the costs associated with separate women's health clinics for primary care (WHC/PC) vs. designating women's health providers in general primary care clinics (GEN/PC).

FINDINGS/RESULTS:
We have completed development of an evidence-based organizational taxonomy for use in classifying VA medical centers along a continuum of care features, which we then used to develop, pilot test, revise and field the 2006-07 VHA Survey of Women Veterans Health Programs & Practices (100%, 93% and 86% response rates at the VISN, VAMC and practice levels, respectively). Women veterans' ratings of accessibility, continuity and coordination are significantly higher in VAs that have adopted WHC/PCs. Analyses of structural features associated with women's chronic disease quality and preventive practices show mixed results for GEN/PC vs. WHC/PC, with distinguishable care features within respective care models demonstrating key associations (e.g., WHC/PCs perform better with higher staffmix). WHC/PC clinics had slightly more provider fulltime equivalents (FTEs) and more visits/provider but lower provider labor costs per visit than GEN/PCs.

IMPACT:
This project represents the first attempt in VHA to systematically evaluate the quality of care for women veterans in VA settings, filling a crucial gap in our ability to reduce gender disparities and to arm VA health care managers with an evidence-base for adapting care arrangements that optimize the outcomes and satisfaction of women veterans.

PUBLICATIONS:

Journal Articles

  1. Reddy SM, Rose DE, Burgess JF, Charns MP, Yano EM. The Role of Organizational Factors in the Provision of Comprehensive Women's Health in the Veterans Health Administration. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2016 Nov 1; 26(6):648-655.
  2. Bastian LA, Bosworth HB, Washington DL, Yano EM. Setting the stage: Research to inform interventions, practice and policy to improve women veterans' health and health care. Journal of general internal medicine. 2013 Jul 1; 28 Suppl 2:S491-4.
  3. Oishi SM, Rose DE, Washington DL, MacGregor C, Bean-Mayberry B, Yano EM. National variations in VA mental health care for women veterans. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2011 Jul 1; 21(4 Suppl):S130-7.
  4. Sambamoorthi U, Bean-Mayberry B, Findley PA, Yano EM, Banerjea R. Organization of care and diagnosed depression among women veterans. The American journal of managed care. 2010 Sep 1; 16(9):657-65.
  5. Bean-Mayberry B, Yano EM, Mor MK, Bayliss NK, Xu X, Fine MJ. Does sex influence immunization status for influenza and pneumonia in older veterans? Journal of the American Geriatrics Society. 2009 Aug 1; 57(8):1427-32.
  6. Bean-Mayberry B, Yano EM, Bayliss N, Navratil J, Weisman CS, Scholle SH. Federally funded comprehensive women's health centers: leading innovation in women's healthcare delivery. Journal of women's health. 2007 Nov 1; 16(9):1281-90.
  7. Bean-Mayberry BA, Yano EM, Caffrey CD, Altman L, Washington DL. Organizational characteristics associated with the availability of women's health clinics for primary care in the Veterans Health Administration. Military medicine. 2007 Aug 1; 172(8):824-8.
  8. Yano EM, Goldzweig C, Canelo I, Washington DL. Diffusion of innovation in women's health care delivery: the Department of Veterans Affairs' adoption of women's health clinics. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2006 Sep 1; 16(5):226-35.
  9. Murdoch M, Bradley A, Mather SH, Klein RE, Turner CL, Yano EM. Women and war. What physicians should know. Journal of general internal medicine. 2006 Mar 1; 21 Suppl 3:S5-10.
  10. Yano EM, Bastian LA, Frayne SM, Howell AL, Lipson LR, McGlynn G, Schnurr PP, Seaver MR, Spungen AM, Fihn SD. 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 Mar 1; 21 Suppl 3:S93-101.
Journal Other

  1. Hamilton A, Poza I, Hines V, Washington DL. Barriers to Psychosocial Services Among Homeless Women Veterans. [Abstract]. Journal of social work practice in the addictions. 2012 Feb 22; 12(1):52-68.
  2. Yano EM, Bean-Mayberry B, Rose DE, Canelo IA, Washington DL. Women and war: How are Veterans Health Administration (VA) facilities adapting to their changing demographics? [Abstract]. Journal of general internal medicine. 2009 Jun 1; 24(S1):S220.
Conference Presentations

  1. Maciejewski ML, Liu CF, Bryson CL, Sharp N, Burgess J. Use of Outpatient Care in VA and Medicare among Disability-Eligible and Age-Eligible Veterans. Paper presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 30; Minneapolis, MN.
  2. Yano EM. Women veterans’ health care in VA. Presented at: VA Syracuse VAMC Center for Integrated Healthcare Seminar; 2009 Mar 26; Syracuse, NY.
  3. Bean-Mayberry BA, Fine MJ, Mor MK, Rose DE, Wright S, Yano EM. Gender and equity in the VA: does quality of care look the same by gender? Paper presented at: VA HSR&D National Meeting; 2009 Feb 12; Baltimore, MD.
  4. Yano EM, Bean-Mayberry BA, Canelo I, Lanto A, Washington DL. What does women's health care look like in the Veterans Health Administration?: Results of a national organizational survey. Poster session presented at: AcademyHealth Annual Research Meeting; 2008 Jun 8; Washington, DC.
  5. Bean-Mayberry B, Yano EM, Mor MK, Wang M, Fine MJ. Does race affect cancer screening among women in VA care? Paper presented at: Society of General Internal Medicine Annual Meeting; 2008 Apr 9; Pittsburgh, PA.
  6. Bean-Mayberry BA, Yano EM, Mor MK, Wang M, Fine MJ. Does race affect cancer screening among women in VA care? Poster session presented at: VA HSR&D National Meeting; 2008 Feb 14; Baltimore, MD.
  7. Mor MK, Cheng C, Bean-Mayberry B, Tang G, Stone RA. Comparison of statistical methods to account for missing race in VA administrative data. Paper presented at: VA HSR&D National Meeting; 2008 Feb 14; Baltimore, MD.
  8. Mor MK, Cheng C, Tang G, Bean-Mayberry B, Stone RA. A comparison of methods to impute missing race in VA administrative data. Paper presented at: American Statistical Association Joint Statistical Annual Meeting; 2007 Aug 1; Salt Lake City, UT.
  9. Bean-Mayberry B, Yano E, Wang M, Mor MK, Fine MJ. Do gender and race affect quality of care in the VA healthcare system? Paper presented at: Society of General Internal Medicine Annual Meeting; 2007 Apr 28; Toronto, Canada.
  10. Liu CF, Yano EM, Ransom S, Maciejewski M. Comparisons of Utilization and Costs among Women Veterans Obtaining Primary Care in Community clinics and Veterans Affairs (VA) Medical Centers. Paper presented at: American Society of Health Economists Biennial Conference; 2006 Jun 1; Madison, WI.
  11. Bean-Mayberry, Brucker J, Bayliss, Xu, Mor K, Yano, Fine J. Effect of gender and race on receipt of pneumococcal and influenza vaccines in VA. Paper presented at: Society of General Internal Medicine Annual Meeting; 2006 Apr 27; Los Angeles, CA.
  12. Bean-Mayberry BA, Brucker N, Bayliss N, Xu X, Mor M, Crick E, Yano E, Fine MJ. Effect of gender and race on receipt of influenza and pneumococcal immunizations in VA. Paper presented at: VA HSR&D National Meeting; 2006 Feb 1; Arlington, VA.
  13. Wright SM, Fleming BB, Craig T, Nilan L, Washington DL, Ash AS, Yano EM. Quality of care and race in the VA. Paper presented at: VA HSR&D National Meeting; 2006 Feb 1; Arlington, VA.
  14. Yano EM, Goldzweig C, Canelo I, Washington DL. Diffusion of innovation: the VA's experiment in delivering comprehensive women's health care. Paper presented at: VA HSR&D National Meeting; 2006 Feb 1; Arlington, VA.
  15. Yano EM. Integrating Gender into the Measurement and Design of Health Care Delivery. Paper presented at: AcademyHealth Annual Research Meeting; 2005 Jun 1; Boston, MA.


DRA: Health Systems
DRE: none
Keywords: Women - or gender differences
MeSH Terms: none

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