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CRE 12-031 – HSR&D Study

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CRE 12-031
Controlled Trial of Tele-Support and Education for Womens Health Care in CBOCs
Donna L Washington MD MPH
VA Greater Los Angeles Healthcare System, West Los Angeles, CA
West Los Angeles, CA
Funding Period: March 2013 - February 2018

BACKGROUND/RATIONALE:
Women Veterans are a rapidly growing proportion of VA patients. However, the VA primary care workforce has limited experience caring for women, particularly their gender-specific conditions. To ensure quality care for women Veterans, in 2010, VA mandated designated women's health (WH) primary care providers (DWHPs) in every VA site, and instituted intensive training opportunities - "WH mini-residencies" - for these providers. Although highly valuable in delivering a standard level of specialized WH training, previous work has shown that these one-time trainings are not sufficient, as knowledge attenuates over time. To address this concern, VA implemented two innovations: (1) serial patient-based education and consultation delivered via clinical video-teleconferencing to address gynecology conditions managed in primary care clinical settings (GYN SCAN-ECHO), and (2) medical record-based interactive communication between DWHPs and gynecologists (gynecology electronic consultations [e-consults]). These innovations are technology-supported and delivered virtually; combined, they are called "DWHP Support."

OBJECTIVE(S):
(1) Assess effect of DWHP Support on WH care quality and efficiency; (2) Explore its impact in changing DWHP clinical practices and self-rated WH knowledge, skills, and self-efficacy; (3) Assess attitudes about DWHP Support, its implementation, and other features that could influence effectiveness, sustainability and spread; and (4) Develop tools to measure quality of VA primary care of gynecologic conditions.

METHODS:
We used mixed methods (incorporating provider/stakeholder interviews, surveys, and field notes) to formatively evaluate DWHP Support, assessing DWHPs' learning needs and DWHP Support implementation and effects. We used literature scans and expert panel methodology to translate existing evidence-based gynecology care guidelines into quality metrics applicable to VA primary care, and developed tools for applying these metrics to VA electronic health records (EHRs). We conducted a prospective, modified stepped wedge trial of DWHP Support, based on measurement of WH care quality using these EHR-based tools. Additionally, where comparable metrics were available for community care, we analyzed VA care quality in comparison to community care.

FINDINGS/RESULTS:
During initial implementation of DWHP Support, the breadth of primary care WH conditions was covered. Formative evaluation revealed that rotating specialists and topics across the breadth of WH limited submission of cases. Based on these findings, the scope of DWHP Support was focused to primary care gynecology issues.

DWHPs' attitudes about DWHP Support were positive. Gynecology SCAN-ECHO participants found it useful for building and maintaining their WH knowledge. In post-session surveys (n=58), 90% of respondents indicated that the information provided would influence patient care (diagnostic, treatment, and/or patient interaction). DWHP interviews (n=26) reported that the sessions increased their knowledge of patient care issues, such as differential diagnoses, understanding evidence behind guidelines, and breadth of management options. Additionally, these DWHPs reported an improved ability to provide patient education and counseling, engaging patients in shared decision-making conversations, and sensitivity to women's psychosocial issues. With respect to gynecology e-consults, all e-consult interviewees (n=32) reported having an overall positive experience with e-consults, and identified benefits in patient care, including improving clinical efficiency and enhancing DWHPs' knowledge and care quality. Nine interviewees identified potential barriers or limitations to e-consults, including increased workload to implement specialist recommendations.

We also assessed DWHPs' relative confidence and learning interests in WH topics. Interviewees expressed greater interest in learning about topics related to conditions they more frequently encountered in their clinics, or that they anticipated seeing more frequently in the future. Interviewees were less interested in learning about topics if they perceived themselves as already having competency or recent training in it, or for conditions they perceived as being less appropriate for management in primary care. Interviews revealed that DWHP Support was one of multiple learning modalities concurrently used by DWHPs.

We measured the quality of primary care provided by DWHPs across four VA healthcare systems for abnormal uterine bleeding (AUB), contraception management, menopause symptoms, and urinary incontinence (UI). Within these conditions, documented adherence to quality guidelines varied widely across guidelines. For example, in AUB care, documented adherence to guidelines related to AUB in menopause was higher compared to pre-menopausal AUB care. Separately, there was wide variation, by metric, in adherence to prescribing guidelines for contraception in women with selected high-risk medical conditions, as well as for systemic hormone therapy for menopause symptom management. For UI care, community comparisons were available, and revealed that variation in VA UI primary care quality was similar to the variation in UI care quality seen in the community. Over the course of the stepped-wedge trial, although VA quality of care increased over time, this occurred independently of exposure to DWHP Support.

IMPACT:
Our findings have been used to guide educational initiatives for DWHPs, including the modification of DWHP Support to focus on gynecology. The quality metrics we developed advance the science of WH quality measurement by expanding the scope of available quality measures and by providing a more comprehensive quality assessment than existing publicly-available measures, which are generally limited to processes of care isolated to a single point in time. The variation in VA WH care quality we identified suggests that quality improvement and educational initiatives need to continue targeting improved guideline adherence in VA primary care for women Veterans across the lifespan. Determinants of quality variation, as well as quality assessments in other settings through which VA delivers or contracts for WH care delivery, should be conducted. To facilitate future quality assessments and monitoring, continued EHR functionality and support for assessment of quality metrics is required. Findings underscore that, to ensure that patients are getting care guided by the current evidence, health care systems must reach beyond traditional modalities for providing continuing education to their providers, and supply "just-in-time" information and decision support. The quality metrics we developed provide the foundation for formulating needed computerized clinical decision support tools, at the point-of-care and/or in support of panel management programs, by making transparent actions that are important in WH primary care. This work also provides an approach for assessing the effects of these efforts.

PUBLICATIONS:

Journal Articles

  1. Cordasco KM, Yuan AH, Danz MJ, Jackson L, Yee EF, Tcheung LS, Washington DL. Veterans Health Administration Primary Care Provider Adherence to Prescribing Guidelines for Systemic Hormone Therapy in Menopausal Women. Journal for healthcare quality : official publication of the National Association for Healthcare Quality. 2019 Mar 1; 41(2):99-109.
  2. Cordasco KM, Yuan AH, Danz MJ, Farmer MM, Jackson L, Yee EF, Washington DL. Guideline Adherence of Veterans Health Administration Primary Care for Abnormal Uterine Bleeding. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2019 Mar 1; 29(2):144-152.
  3. Washington DL, Danz M, Jackson L, Cordasco KM. Development of Quality Indicators for the Care of Women with Abnormal Uterine Bleeding by Primary Care Providers in the Veterans Health Administration. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2019 Mar 1; 29(2):135-143.
  4. Zuchowski JL, Hamilton AB, Washington DL, Gomez AG, Veet L, Cordasco KM. Drivers of Continuing Education Learning Preferences for Veterans Affairs Women's Health Primary Care Providers. The Journal of Continuing Education in The Health Professions. 2017 Jan 1; 37(3):168-172.
  5. Cordasco KM, Zuchowski JL, Hamilton AB, Kirsh S, Veet L, Saavedra JO, Altman L, Knapp H, Canning M, Washington DL. Early lessons learned in implementing a women's health educational and virtual consultation program in VA. Medical care. 2015 Apr 1; 53(4 Suppl 1):S88-92.
  6. deKleijn M, Lagro-Janssen AL, Canelo I, Yano EM. Creating a roadmap for delivering gender-sensitive comprehensive care for women Veterans: results of a national expert panel. Medical care. 2015 Apr 1; 53(4 Suppl 1):S156-64.
  7. Yano EM. A partnered research initiative to accelerate implementation of comprehensive care for women veterans: the VA women's health CREATE. Medical care. 2015 Apr 1; 53(4 Suppl 1):S10-4.
Online News Media Articles

  1. Yano EM. VA researchers, clinicians and policymakers partner to help women Veterans. VAntage Point: Official Blog of the U.S. Department of Veterans Affairs [Internet]. 2015 Apr 7. Available from: http://www.blogs.va.gov/VAntage/18744/va-researchers-clinicians-and-policymakers-partner-to-help-women-veterans/.
HSR&D or QUERI Articles

  1. Washington DL, Cordasco KM. Tele-Support for Women's Healthcare in VA Community-Based Outpatient Clinics. VA HSRD July 2016 News Feature: Improving Access to Care through Telehealth. 2016 Jul 1.
Center Products

  1. Hanks D, Hecht MI, Auffrey RR, Washington DL. Podcast-4: Live from the Meeting: Measuring Quality of Care for Women Veterans. 2017 Jun 27. 1 (4). Available from: https://www.hsrd.research.va.gov/news/podcasts/default.cfm.
VA Cyberseminars

  1. Yano EM, Frayne S, Strauss J, Sadler A. Overview of VA Women's Health Research. Research Breakout Session on Women Veterans Health Research in VA [Cyberseminar]. National Women Veterans Summit. 2017 Nov 9.
Government Briefings

  1. Yano EM. VA's Research Efforts on Women Veterans. Panelist Briefing at Capitol Hill Lunch and Learn Event on Women Veterans. In Response to "Women Veterans: The Journey Ahead," a Report from Disabled American Veterans (DAV): Briefing before the members and staffers of the US Congress; 2018 Sep 12; Capitol Hill Visitor Center, Washington DC.
  2. Yano EM. Advances in Women Veterans Research: Briefing before the National Association of State Women Veteran Coordinators; 2018 Jun 25; Alexandria, VA.
  3. Yano EM. VA Research Day on the Hill: Briefing before the members and staffers of the US Congress; 2018 Jun 19; Washington, DC.
  4. Yano EM. Women Veterans Research: Briefing before the VA Advisory Committee on Women Veterans; 2018 May 9; Washington, DC.
  5. Haskell S, Yano EM. Veterans Health Research: A Focus on Women: Briefing before the US Congress; 2016 Feb 22; Washington, DC.
Conference Presentations

  1. Tcheung Le, Cordasco KM, Danz M, Bell-Lewis L, Washington DL. Methods for Measuring Primary Care Providers’ Quality of Care for Urinary Incontinence. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2016 May 11; Hollywood, FL.
  2. Zuchowski JL, Hamilton AB, Washington DL, Gomez A, Veet L, Cordasco KM. What Do Women’s Health Primary Care Providers Need and Want to Know?: Learning Interests and Confidence of VA Women’s Health PCPs. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2016 May 11; Hollywood, FL.
  3. Cordasco KM, Zuchowski JL, Hamilton AB, Canning MT, Bell-Lewis L, Chrystal JG, Kirsh S, Washington DL. Veterans Health Administration Electronic Consultations. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.
  4. Washington DL, Danz M, Bell-Lewis L, Cordasco KM. Development of an Electronic Health Record Quality Measurement Tool for the Care of Women with Abnormal Uterine Bleeding. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.
  5. Cordasco KM, Zuchowski J, Hamilton AB, Canning MT, Bell-Lewis L, Chrystal JG, Kirsh S, Washington DL. Veterans Health Administration Electronic Consultations:  Women’s Health Primary Care Providers’ Perceptions. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2015 Apr 23; Toronto, Canada.
  6. Cordasco KM, Zuchowski J, Hamilton A, Knapp H, Saavedra JO, Altman L, Washington DL. Insights from Implementing VA's Comprehensive Women's Health SCAN-ECHO Program. Paper presented at: VA HSR&D Enhancing Partnerships for Research and Care of Women Veterans Conference; 2014 Jul 31; Arlington, VA.
  7. Washington DL, Danz M, Bell-Lewis L, Cordasco KM. Partnered Research for Development of Quality Indicators for the Care of Women with Abnormal Uterine Bleeding. Poster session presented at: VA HSR&D Enhancing Partnerships for Research and Care of Women Veterans Conference; 2014 Jul 31; Arlington, VA.
  8. Zuchowski J, Washington DL, Cordasco KM. Assessing the Learning Needs of VHA Women’s Health Primary Care Providers. Poster session presented at: VA HSR&D Enhancing Partnerships for Research and Care of Women Veterans Conference; 2014 Jul 31; Arlington, VA.
  9. Cordasco KM, Zuchowski J, Hamilton A, Knapp H, Saavedra JO, Altman L, Washington DL. Lessons Learned in Implementing VA’s Comprehensive Women’s Health SCAN-ECHO Program. Poster session presented at: AcademyHealth Annual Research Meeting; 2014 Jun 8; San Diego, CA.
  10. Hamilton A, Washington DL, Cordasco KM, Zuchowski J. Assessing the Learning Needs of VHA Women's Health Primary Care Providers. Poster session presented at: AcademyHealth Annual Research Meeting; 2014 Jun 8; San Diego, CA.
  11. Washington DL, Danz M, Cordasco KM. Quality Assessment of Abnormal Uterine Bleeding Care: Results of an Expert Panel Process. Poster session presented at: AcademyHealth Annual Research Meeting; 2014 Jun 8; San Diego, CA.
  12. Cordasco KM, Zuchowski J, Hamilton A, Knapp H, Saavedra JO, Altman L, Washington DL. VHA’s Comprehensive Women’s Health SCAN-ECHO Program: Lessons Learned. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2014 Apr 25; San Diego, CA.
  13. Washington DL, Danz M, Cordasco KM. Development of Quality Indicators for the Care of Women with Abnormal Uterine Bleeding. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2014 Apr 25; San Diego, CA.
  14. Zuchowski J, Hamilton A, Washington DL, Cordasco KM. Learning Needs of VHA Women’s Health Providers. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2014 Apr 25; San Diego, CA.


DRA: Health Systems
DRE: Diagnosis
Keywords: Attitudes/Beliefs, Efficiency, Knowledge Integration, Models of Care, Organizational Structure, Provider Education, Quality of Care, Rural, Telemedicine/Telehealth, Utilization
MeSH Terms: none