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CDA 14-412 – HSR&D Study

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CDA 14-412
Reproductive Planning for Women Veterans
Lisa S Callegari MD
VA Puget Sound Health Care System Seattle Division, Seattle, WA
Seattle, WA
Funding Period: October 2015 - September 2020

BACKGROUND/RATIONALE:
The number of women Veterans using VA health care has doubled over the past 10 years, with almost half of female VA users now of reproductive age. Women Veterans have high rates of medical and mental health comorbidities that elevate their risk of poor pregnancy outcomes, however nearly 30% of those at risk of unintended pregnancy are not using prescription contraception and few receive preventive preconception counseling or services before pregnancy. Interventions are needed in VA to address gaps in counseling and decision support for pregnancy planning and contraceptive decisions. Growing evidence supports use of patient-facing decision support tools to improve decision quality, provider-patient communication, and health outcomes.

OBJECTIVE(S):
This CDA-2 will develop and test a patient-centered, patient-facing decision support tool to promote informed decisions and shared decision making regarding reproductive planning in VA primary care.

1. To determine pregnancy planning and contraceptive decision support preferences and needs among women Veterans and VA primary care providers (PCPs).

2. To develop and refine a web-based decision support tool and pilot its use in VA primary care to assess acceptability, feasibility, and preliminary efficacy outcomes.

3. To test the effect of the decision support tool compared to usual care on decision quality and outcomes, including contraceptive use and preconception health behaviors, and to identify implementation barriers and facilitators.

METHODS:
Aim 1 will utilize both quantitative and qualitative methods to investigate decision support preferences and needs of women Veterans and VA PCPs. Data will be analyzed from a national survey of 2,302 reproductive-aged women Veterans to identify preferences related to contraception and contraceptive counseling, including variations by sociodemographic and health characteristics. In-depth qualitative interviews will explore preferences and needs of women Veterans and VA PCPs related to pregnancy planning and contraceptive decision support. Aim 2 will draw on Aim 1 findings to develop content for the tool in a user-centered, iterative process based on the International Patient Decision Aid Standards (IPDAS) and engage a software development team to build an interactive web-based tool configured for an iPad. A pilot study will evaluate acceptability, feasibility, and preliminary outcomes of use of the tool on in primary care clinics. Aim 3 will test the effect of the tool compared to usual care in a multisite randomized controlled trial evaluating decision quality (knowledge, self-efficacy, decision conflict) and provider-patient communication; clinical outcomes (contraceptive use, preconception health behaviors, unintended pregnancy); and implementation barriers and facilitators.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
Given the projected growth in numbers of reproductive-aged women Veterans using VA, efforts to improve quality of care and services for this population will continue to be a high priority nationally. This CDA2 employs innovative patient-centered strategies and technology to address gaps in current VA reproductive health services with the goal of improving both patient-centered and clinical outcomes among women Veterans.

PUBLICATIONS:

Journal Articles

  1. Callegari LS, Edmonds SW, Borrero S, Ryan GL, Cusack CM, Zephyrin LC. Preconception Care in the Veterans Health Administration. Seminars in reproductive medicine. 2019 Apr 19; 36(6):327-339.
  2. Katon JG, Zephyrin L, Meoli A, Hulugalle A, Bosch J, Callegari L, Galvan IV, Gray KE, Haeger KO, Hoffmire C, Levis S, Ma EW, Mccabe JE, Nillni YI, Pineles SL, Reddy SM, Savitz DA, Shaw JG, Patton EW. Reproductive Health of Women Veterans: A Systematic Review of the Literature from 2008 to 2017. Seminars in reproductive medicine. 2019 Apr 19; 36(6):315-322.
  3. Callegari LS, Tartaglione EV, Magnusson SL, Nelson KM, Arteburn DE, Szarka J, Zephyrin L, Borrero S. Understanding Women Veterans' Family Planning Counseling Experiences and Preferences to Inform Patient-Centered Care. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2019 May 1; 29(3):283-289.
  4. McCabe JE, Katon JG, Ma E, Fortney JC, Grote NK, Zephyrin LC, Callegari LS. Preconception Health Risk Factors in Women with and without a History of Military Service. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2018 Nov 1; 28(6):539-545.
  5. Callegari LS, Katon JG, Gray KE, Doll K, Pauk S, Lynch KE, Uchendu US, Zephyrin L, Gardella C. Associations between Race/Ethnicity, Uterine Fibroids, and Minimally Invasive Hysterectomy in the VA Healthcare System. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2019 Jan 1; 29(1):48-55.
  6. Wolgemuth T, Judge-Golden C, Callegari L, Zhao X, Mor M, Borrero S. Associations between Pregnancy Intention, Attitudes, and Contraceptive Use among Women Veterans in the ECUUN Study. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2018 Nov 1; 28(6):480-487.
  7. Judge-Golden CP, Borrero S, Zhao X, Mor MK, Callegari LS. The Association between Mental Health Disorders and History of Unintended Pregnancy among Women Veterans. Journal of general internal medicine. 2018 Dec 1; 33(12):2092-2099.
  8. Gilmore K, Ojanen-Goldsmith A, Callegari LS, Godfrey EM. The first 6 months: developing a user-informed anticipatory counselling video about the levonorgestrel intrauterine system. BMJ sexual & reproductive health. 2018 Jun 22.
  9. Birru Talabi M, Clowse MEB, Schwarz EB, Callegari LS, Moreland L, Borrero S. Family Planning Counseling for Women With Rheumatic Diseases. Arthritis care & research. 2018 Feb 1; 70(2):169-174.
  10. Schwarz EB, Sileanu FE, Zhao X, Mor MK, Callegari LS, Borrero S. Induced abortion among women veterans: data from the ECUUN study. Contraception. 2018 Jan 1; 97(1):41-47.
  11. Katon JG, Gray K, Callegari L, Gardella C, Gibson C, Ma E, Lynch KE, Zephyrin L. Trends in hysterectomy rates among women veterans in the US Department of Veterans Affairs. American journal of obstetrics and gynecology. 2017 Oct 1; 217(4):428.e1-428.e11.
  12. Callegari LS, Zhao X, Schwarz EB, Rosenfeld E, Mor MK, Borrero S. Racial/ethnic differences in contraceptive preferences, beliefs, and self-efficacy among women veterans. American journal of obstetrics and gynecology. 2017 May 1; 216(5):504.e1-504.e10.
  13. Borrero S, Callegari LS, Zhao X, Mor MK, Sileanu FE, Switzer G, Zickmund S, Washington DL, Zephyrin LC, Schwarz EB. Unintended Pregnancy and Contraceptive Use Among Women Veterans: The ECUUN Study. Journal of general internal medicine. 2017 Aug 1; 32(8):900-908.
  14. Rosenfeld E, Callegari LS, Sileanu FE, Zhao X, Schwarz EB, Mor MK, Borrero S. Racial and ethnic disparities in contraceptive knowledge among women veterans in the ECUUN study. Contraception. 2017 Jul 1; 96(1):54-61.
  15. Goldstein KM, Callegari LS. Should a history of assisted reproductive technology be another consideration when assessing cardiovascular risk? Journal of clinical hypertension (Greenwich, Conn.). 2017 Feb 1; 19(2):170-172.
  16. Aiken AR, Borrero S, Callegari LS, Dehlendorf C. Rethinking the Pregnancy Planning Paradigm: Unintended Conceptions or Unrepresentative Concepts? Perspectives on sexual and reproductive health. 2016 Sep 1; 48(3):147-51.
  17. Richards MK, Flanagan MR, Littman AJ, Burke AK, Callegari LS. Primary cesarean section and adverse delivery outcomes among women of very advanced maternal age. Journal of Perinatology. 2016 Apr 1; 36(4):272-7.
  18. Callegari LS, Gray KE, Zephyrin LC, Harrington LB, Gerber MR, Cochrane BB, Weitlauf JC, Bean-Mayberry B, Bastian LA, Mattocks KM, Haskell SG, Katon JG. Hysterectomy and Bilateral Salpingo-Oophorectomy: Variations by History of Military Service and Birth Cohort. The Gerontologist. 2016 Feb 1; 56 Suppl 1:S67-77.
  19. Callegari LS, Borrero S, Reiber GE, Nelson KM, Zephyrin L, Sayre GG, Katon JG. Reproductive Life Planning in Primary Care: A Qualitative Study of Women Veterans' Perceptions. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2015 Sep 1; 25(5):548-54.
  20. Torvie AJ, Callegari LS, Schiff MA, Debiec KE. Labor and delivery outcomes among young adolescents. American journal of obstetrics and gynecology. 2015 Jul 1; 213(1):95.e1-8.
  21. Callegari LS, Ma EW, Schwarz EB. Preconception care and reproductive planning in primary care. The Medical Clinics of North America. 2015 May 1; 99(3):663-82.
  22. Gray KE, Katon JG, Callegari LS, Cordasco KM, Zephyrin LC. Gynecologists in the VA: do they enhance availability of sex-specific services and policies in the emergency department? Medical care. 2015 Apr 1; 53(4 Suppl 1):S76-80.
Journal Other

  1. Callegari LS, Aiken AR, Dehlendorf C, Cason P, Borrero S. Addressing potential pitfalls of reproductive life planning with patient-centered counseling. [Editorial]. American journal of obstetrics and gynecology. 2017 Feb 1; 216(2):129-134.
VA Cyberseminars

  1. Callegari LS, Borrero SD. Promoting Patient-Centered Family Planning in VA Through a Novel Web-Based Decision Support Tool. HSR&D Career Development Award Enhancement Initiative [Cyberseminar]. HSR&D. 2018 May 9.
  2. Borrero SB, Callegari LS. Contraceptive Care in the VA Healthcare System: New Insights from a National Survey. Spotlight on Women's Health [Cyberseminar]. HSR&D. 2017 Oct 24.
  3. Callegari L, Katon JG, Weitlauf JC. Women Veterans in the Women's Health Initiative: Reproductive Health and Menopause. Spotlight on Women's Health [Cyberseminar]. VA HSR&D. 2016 Mar 2.
Conference Presentations

  1. Callegari LS. Racial and ethnic differences in contraceptive preferences: findings from the Examining Contraceptive Use and Unmet Need among Women Veterans (ECUUN) Study. Paper presented at: VA HSR&D Field-Based Meeting to Engage Diverse Stakeholders and Operational Partners in Advancing Health Equity in the VA Healthcare System; 2016 Sep 20; Philadelphia, PA.
  2. Callegari LS. Rates of unintended pregnancy, contraceptive use, and unmet contraceptive need among women veterans. Paper presented at: Society of General Internal Medicine Annual Meeting; 2016 May 11; Hollywood, FL.
  3. Callegari LS. The association between mental health disorders and unintended pregnancy among women Veterans. Poster session presented at: North American Forum on Family Planning; 2015 Nov 14; Chicago, IL.
  4. Callegari LS. Associations between Contraceptive Knowledge and Use of Prescription Contraception among Women Veterans. Poster session presented at: North American Forum on Family Planning; 2015 Nov 14; Chicago, IL.


DRA: Health Systems
DRE: Epidemiology, Technology Development and Assessment, Treatment - Comparative Effectiveness, Research Infrastructure
Keywords: Outcomes - Patient
MeSH Terms: none