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CRE 12-019 – HSR Study

CRE 12-019
Lost to Care: Attrition of Women Veterans New to VHA
Susan M Frayne, MD MPH
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Alison Hamilton PhD MPH
VA Greater Los Angeles Healthcare System, West Los Angeles, CA
West Los Angeles, CA
Funding Period: March 2013 - February 2018
With access to care among top VHA priorities, the high rate of attrition from care among women Veterans new to the Veterans Health Administration (VHA) suggested by prior research raised major concerns. Efforts to ensure that women new to VHA have access to high-quality, comprehensive women's health (WH) care must account for perspectives of those not won over by VHA's current delivery system. Therefore, we assessed whether and how patient experiences of VHA care contribute to attrition, patient subgroups at risk for attrition, and promising, patient-centered remedies.

Among women Veterans new to VHA, our specific aims were:
1: To identify predictors of attrition (patient experiences of VHA care, VHA organizational factors, community health care resources, patient factors)
2: To assess longitudinal changes in attrition
3: To understand perspectives of attriters (why they left), and non-attriters (why they stayed)
4: To explore plans for future VHA use among current VHA users

Aims 1 and 2 used quantitative methods with existing databases, including VHA's National Patient Care Database and national VHA organizational data. Aim 1 examined predictors of attrition in a national cohort of women new to VHA in Fiscal Year 2011 (FY11). Aim 2 examined attrition longitudinally in women and men new to VHA in FY07-FY13. Aims 3 and 4 used qualitative methods and involved interviews with attriters and non-attriters from high and low attrition facilities. Our mixed methods design was guided by an innovative combination of Consumer Choice Theory and the Andersen Behavioral Model.

In FY11, 7% of women Veteran patients were new to VHA. Among new women Veteran primary care patients (N=18,398) (Aim 1), 58% were 18-44 years old, 37% were 45-64, and 5% were 65 or older; 63% received care from a women's health primary care provider (WH-PCP). Among new women Veteran primary care patients, 16% attrited (i.e., did not return for VHA care during the two years following their initial year of care). Factors associated with higher odds of attrition included: younger age, lack of service connected disability, unknown race/ethnicity, married, having a VA Medical Center as main site of care, longer travel time, and no fee basis care. The rate of attrition was 12% versus 24% for those who saw a WH-PCP versus another PCP type. Even after adjustment for other factors (sociodemographics, travel time, site of care, fee basis care), those who saw a WH-PCP had less than half the odds of subsequent attrition from VHA. In Aim 2, the attrition rate was similar for new women and men in FY07, overall (23% for both). However, from FY07-FY13 the overall reduction in attrition over time was greater for women than for men, though this varied by age group: (a) Among 18-44 year olds, there was a similar decline in attrition for women versus men; (b) Among 45-64 year olds, the attrition rate after FY10 declined for women but increased for men; and (c) Among those 65 or older, after FY10, the attrition rate increased for both women and men.

Under Aim 3, oversampling attriters at six high and four low attrition facilities, 345 letters were mailed to women meeting eligibility criteria; among the 214 with a usable phone number, 51 (n=25 attriters, n=26 non-attriters; 28% under 45 years old; 61% from a racial/ethnic minority group) completed interviews. Not all women's self-categorization as attriter or non-attriter aligned with our initial categorizations: some attriters considered themselves VHA users, and conversely. Women's main reasons for leaving or only partially using VHA included having to travel too far; finding the VHA to be inconvenient or less satisfying than non-VA care; being dissatisfied with provider selection, provider continuity (e.g., with provider turnover), and/or provider-patient interactions; experiencing challenges with the disability claims process and/or the Veterans Choice process; encountering time conflicts with appointments; not having childcare available; and encountering closed VHA facilities. Current users generally intended to continue using VHA (Aim 4), but for many, this was because they did not have other options.

In addition to ongoing updates to national policy partners throughout the study period, findings were disseminated directly to women Veterans nationally via a Cyberseminar, included as an online feature article in VA HSR&D "In Progress" for the early attention of policy-makers, and included by Women's Health Services in their Congressional briefing kit. Results led the national women's health policy office to incorporate attrition as an additional target for monitoring.

As VHA seeks to make services welcoming and accessible to women Veterans and sensitive to their healthcare needs, those lost to the system represent a group requiring special attention. By examining patient experiences of VHA care and assessing patient and systems characteristics contributing to attrition, this study has identified subgroups at high risk of attrition; new women patients who are younger merit particular attention to ensure their early experiences with VHA are positive, leading them to choose VHA for the long term.

Findings also point to promising targets for intervention at practice and policy levels. For example, seeing a WH-PCP was highly protective against attrition, supporting national comprehensive women's healthcare policy. The fact that more than one in three new women Veteran patients did not see a WH-PCP highlights the likely value of further enhancing women's access to WH-PCPs, and the fact that women reported dissatisfaction with provider turnover supports the importance of retaining trained WH-PCPs in the system. Living farther from a VHA facility was a consistent risk factor for attrition, suggesting the importance of continuing and extending VHA's efforts to bring services to patients via technology innovations, geographically distributed VHA sites of care, or access to outsourced community care (with attention to user-friendly processes for the latter, given some women's frustrations with their experiences). Refining practice and policy by drawing on patient-centered perspectives of women Veterans using VHA services has the potential to advance VHA's objective of being the provider of choice for all Veterans served.

External Links for this Project

NIH Reporter

Grant Number: I01HX000948-01

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Journal Articles

  1. 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. [view]
  2. Hamilton AB, Frayne SM, Cordasco KM, Washington DL. Factors related to attrition from VA healthcare use: findings from the National Survey of Women Veterans. Journal of general internal medicine. 2013 Jul 1; 28 Suppl 2:S510-6. [view]
  3. Friedman S, Shaw JG, Hamilton AB, Vinekar K, Washington DL, Mattocks K, Yano EM, Phibbs CS, Johnson AM, Saechao F, Berg E, Frayne SM. Gynecologist Supply Deserts Across the VA and in the Community. Journal of general internal medicine. 2022 Sep 1; 37(Suppl 3):690-697. [view]
  4. Maisel NC, Haskell S, Hayes PM, Balasubramanian V, Torgal A, Ananth L, Saechao F, Iqbal S, Phibbs CS, Frayne SM. Readying the workforce: evaluation of VHA's comprehensive women's health primary care provider initiative. Medical care. 2015 Apr 1; 53(4 Suppl 1):S39-46. [view]
  5. Friedman SA, Frayne SM, Berg E, Hamilton AB, Washington DL, Saechao F, Maisel NC, Lin JY, Hoggatt KJ, Phibbs CS. Travel time and attrition from VHA care among women veterans: how far is too far? Medical care. 2015 Apr 1; 53(4 Suppl 1):S15-22. [view]
Online News Media Articles

  1. Frayne SM, Hamilton A. Attrition of Women Veterans New to VA. VA HSR&D In Progress: VA Healthcare for Women Veterans [Internet]. 2017 Mar 1. Available from: [view]
  2. 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: [view]
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. [view]
  2. Yano E, Frayne SM, Hamilton A, Washington D, Bastian L, Mattocks K. Spotlight on Women's Health - Using Research to Accelerate Implementation of Comprehensive Women’s Health Care in VHA: VA HSR&D Women’s Health CREATE by Women's Health Consortium. [Cyberseminar]. 2014 Jan 27. [view]
Government Briefings

  1. Yano EM. Advances in Women Veterans Research: Briefing before the National Association of State Women Veteran Coordinators; 2018 Jun 25; Alexandria, VA. [view]
  2. Yano EM. VA Research Day on the Hill: Briefing before the members and staffers of the US Congress; 2018 Jun 19; Washington, DC. [view]
  3. 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. [view]
  4. Haskell S, Yano EM. Veterans Health Research: A Focus on Women: Briefing before the US Congress; 2016 Feb 22; Washington, DC. [view]
  5. Yano EM. Women Veterans Research: Briefing before the VA Advisory Committee on Women Veterans; 2018 May 9; Washington, DC. [view]
Conference Presentations

  1. Hamilton A, Frayne SM, Cordasco KM, Washington DL. Factors Related to Attrition from VA Healthcare Use: Findings from the National Survey of Women Veterans. Poster session presented at: AcademyHealth Annual Research Meeting; 2013 Jun 24; Baltimore, MD. [view]
  2. Friedman SA, Phibbs CS, Hamilton A, Berg E, Washington D, Maisel N, Frayne SM. How far is too far? Distance and women Veterans' attrition from VHA. Paper presented at: AcademyHealth Annual Research Meeting; 2014 Jun 7; San Diego, CA. [view]
  3. Phibbs C, Hamilton AB, Berg E, Washington DL, Maisel NC, Frayne S. How far is too far? Distance and women Veterans’ attrition from VHA. Paper presented at: VA HSR&D Enhancing Partnerships for Research and Care of Women Veterans Conference; 2014 Jul 31; Arlington, VA. [view]
  4. Frayne SM, Phibbs CS, Berg E, Friedman SA, Yano EM, Washington DL, Saechao FS, Finlay AK, Hoggatt K, Hamilton AB. One foot in the door and one foot out: Attrition among women community care users who have recently joined the VA. VA National Meeting: Examining the New Landscape of Care in the Community for Veterans. Paper presented at: VA HSR&D Field-Based Examining the New Landscape of Care in the Community for Veterans Meeting; 2016 Aug 8; Arlington, VA. [view]
  5. Friedman SA, Phibbs CS, Hamilton A, Washington DL, Yano E, Hayes PM, Haskell S, Frayne SM. Too sick to attrit? Does health status change the likelihood that new women Veterans will attrit from VHA care? Poster session presented at: University of California Los Angeles Scientific Retreat; 2013 Oct 21; Los Angeles, CA. [view]
  6. Friedman SA, Frayne SM, Hamilton AB, Washington DL, Saechao F, Maisel NC, Lin J, Phibbs CS, Berg E. Travel time and attrition among women Veterans: How far is too far? Paper presented at: VA HSR&D Enhancing Partnerships for Research and Care of Women Veterans Conference; 2014 Jul 31; Arlington, VA. [view]

DRA: Health Systems
DRE: none
Keywords: none
MeSH Terms: none

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