Bevanne Bean-Mayberry

Integration of Women Veterans into VA Quality Improvement Research Efforts: What Researchers Need to Know

The Department of Veterans Affairs (VA) and other federal agencies require funded researchers to include women in their studies. Historically, many researchers have indicated they will include women in proportion to their VA representation or pointed to their numerical minority as justification for exclusion. However, women’s participation in the military—currently 14% of active military—is rapidly changing veteran demographics, with women among the fastest growing segments of new VA users. These changes will require researchers to meet the challenge of finding ways to adequately represent women veterans for meaningful analysis. We describe women veterans’ health and health-care use, note how VA care is organized to meet their needs, report gender differences in quality, highlight national plans for women veterans’ quality improvement, and discuss VA women’s health research. We then discuss challenges and potential solutions for increasing representation of women veterans in VA research, including steps for implementation research.

Racial/Ethnic Variations in Physician Recommendations for Cardiac Revascularization

OBJECTIVES We sought to examine whether physician recommendations for cardiac revascularization vary according to patient race. METHODS We studied patients scheduled for coronary angiography at 2 hospitals, one public and one private, between November 1997 and June 1999. Cardiologists were interviewed regarding their recommendations for cardiac resvacularization. RESULTS African American patients were less likely than Whites to be recommended for revascularization at the public hospital (adjusted odds ratio [OR] = 0.31; 95% confidence interval [CI] = 0.12, 0.77) but not at the private hospital (adjusted OR = 1.69; 95% CI = 0.69, 4.14). CONCLUSIONS Physician recommendations for cardiac revascularization vary by patient race. Further studies are needed to examine physician bias as a factor in racial disparities in cardiac care and outcomes.

Patient satisfaction in women's clinics versus traditional primary care clinics in the Veterans Administration.

AbstractOBJECTIVE: To compare patient satisfaction in women’s clinics (WCs) versus traditional primary care clinics (TCs). DESIGN: Anonymous, cross-sectional mailed survey. SETTING: Eight Department of Veterans Affairs (VA) medical centers in 3 states. PATIENTS: A random sample of women stratified by site and enrollment in WC versus TC (total response rate = 61%). MEASURES: Overall satisfaction and gender-specific satisfaction as measured by the Primary Care Satisfaction Survey for Women (PCSSW). ANALYSIS: We dichotomized the satisfaction scores (excellent versus all other), and compared excellent satisfaction in WCs versus TCs using logistic regression, controlling for demographics, health status, health care use, and location. RESULTS: Women enrolled in WCs were more likely than those in TCs to report excellent overall satisfaction (odds ratio, 1.42; 95% confidence interval, 1.00 to 2.02; P=.05). Multivariate models demonstrated that receipt of care in WCs was a significant positive predictor for all 5 satisfaction domains (i.e., getting care, privacy and comfort, communication, complete care, and follow-up care) with the gender-specific satisfaction instrument (PCSSW). CONCLUSIONS: This study is the first to consistently show higher satisfaction in WCs versus TCs despite age and race differences and comparable health status. Since these WCs show better quality in terms of satisfaction, other quality indicators should be evaluated. If WCs reduce fragmentation and improve health care delivery, the model will be applicable in VA and non-VA outpatient settings.

Women Veterans’ Healthcare Delivery Preferences and Use by Military Service Era: Findings from the National Survey of Women Veterans

ABSTRACTBACKGROUNDThe number of women Veterans (WVs) utilizing the Veterans Health Administration (VA) has doubled over the past decade, heightening the importance of understanding their healthcare delivery preferences and utilization patterns. Other studies have identified healthcare issues and behaviors of WVs in specific military service eras (e.g., Vietnam), but delivery preferences and utilization have not been examined within and across eras on a population basis.OBJECTIVETo identify healthcare delivery preferences and healthcare use of WVs by military service era to inform program design and patient-centeredness.DESIGN AND PARTICIPANTSCross-sectional 2008–2009 survey of a nationally representative sample of 3,611 WVs, weighted to the population.MAIN MEASURESHealthcare delivery preferences measured as importance of selected healthcare features; types of healthcare services and number of visits used; use of VA or non-VA; all by military service era.KEY RESULTSMilitary service era differences were present in types of healthcare used, with World War II and Korea era WVs using more specialty care, and Vietnam era-to-present WVs using more women’s health and mental health care. Operations Enduring Freedom, Iraqi Freedom, New Dawn (OEF/OIF/OND) WVs made more healthcare visits than WVs of earlier military eras. The greatest healthcare delivery concerns were location convenience for Vietnam and earlier WVs, and cost for Gulf War 1 and OEF/OIF/OND WVs. Co-located gynecology with general healthcare was also rated important by a sizable proportion of WVs from all military service eras.CONCLUSIONSOur findings point to the importance of ensuring access to specialty services closer to home for WVs, which may require technology-supported care. Younger WVs’ higher mental health care use reinforces the need for integration and coordination of primary care, reproductive health and mental health care.

AVAILABILITY OF GYNECOLOGIC SERVICES IN THE DEPARTMENT OF VETERANS AFFAIRS

PURPOSE The optimum approach to providing the Congressionally mandated gender-specific services for which women veterans are eligible is unknown. We evaluated onsite availability of gynecologic services, clinic type and staffing arrangements, and the impact of having a gynecology clinic (GYN) and/or an obstetrician gynecologist (OBGYN) routinely available. METHODS We analyzed data from the 2001 national VHA Survey of Women Veterans Health Programs and Practices (n = 136 sites; response rate, 83%). We assessed availability of gynecologic services, and evaluated differences in availability by clinic type (designated womens health provider in primary care [PC], separate womens health clinic for primary care [WHC], and/or separate GYN) and staffing arrangements (OBGYN routinely involved versus not). MAIN FINDINGS Out of 133 sites, 77 sites (58%) offered services through a GYN and 56 sites (42%) did not have GYN. Seventy-two (54%) sites had a WHC. More sites with an OBGYN provided endometrial biopsies (91% vs. 20%), IUD insertion (85% vs. 14%), infertility evaluation (56% vs. 23%), infertility treatment (25% vs. none), gynecologic surgery (65 vs. 28%), p < .01. In comparison to sites without WHC, those with WHC were more likely to offer services onsite: endometrial biopsy odds ratio (OR) 6.0 (95% confidence interval [CI], 2.0-18.1); IUD insertion 4.4 (1.6-12.2); infertility evaluation 2.8 (1.2-6.3); and gynecologic surgery 2.3 (1.0-5.4). CONCLUSION As the VA develops strategic plans for accommodating the growing number of women veterans, leaders should consider focusing on establishing WHC for primary care and routine availability of OBGYN or other qualified clinicians, rather than establishing separate GYN.

National variations in VA mental health care for women veterans.

OBJECTIVES Although the Veterans Health Administration (VA) has recently adopted new policies encouraging gender-specific mental health (MH) care delivery to women veterans, little is known about the potential difficulties local facilities may face in achieving compliance. We assessed variations in womens mental health care delivery arrangements in VA facilities nationwide. METHODS We used results from the VA Survey of Women Veterans Health Programs, a key informant survey of senior womens health clinicians representing all VA facilities serving more than 300 women veterans, to assess the array of gender-sensitive mental health care arrangements (response rate, 86%; n = 195). We also examined organizational and area factors related to availability of womens specialty mental health arrangements using multivariable logistic regression. RESULTS Nationally, over half (53%) of VA facilities had some form of gender-sensitive mental health care arrangements. Overall, 34% of sites reported having designated womens mental health providers in general outpatient mental health clinics (MHCs). Almost half (48%) had therapy groups for women in their MHCs. VAs with womens primary care clinics also delivered mental health services (24%), and 12% of VAs reported having a separate womens MHC, most of which (88%) offered sexual trauma group counseling. Assignment to same-gender mental health providers is not routine. VAs with comprehensive womens primary care clinics were more likely to integrate mental health care for women as well. CONCLUSION Local implementation of gender-sensitive mental health care in VA settings is highly variable. Although this variation may reflect diverse local needs and resources, women veterans may also sometimes face challenges in accessing needed services.

Discontinuing postmenopausal hormone therapy: an observational study of tapering versus quitting cold turkey: is there a difference in recurrence of menopausal symptoms?

Objective: Because no current evidence-based guidelines for postmenopausal hormone therapy (HT) discontinuation strategies exist, we compared female veterans who tapered HT to those who stopped abruptly with regard to patient-specific health factors and recurrence of menopausal symptoms. Methods: We identified female veterans who used combined estrogen/medroxyprogesterone HT in 2001 using the VA Pharmacy Benefits Management database. We then randomly sorted and selected 4,000 women for a mailed invitation to participate in a HT survey. Women who agreed to participate were mailed the National Women Veterans Hormone Replacement Survey. Results: Of 836 participants who discontinued HT, 75% stopped cold turkey and 25% tapered. In bivariate analysis, taperers were more likely to report higher incomes, less smoking, and more use of alternatives such as vitamin E, other dietary supplements, and exercise or yoga for menopausal symptoms. They also more frequently reported discussions of menopausal symptoms with providers and used HT for menopausal symptoms and had longer median years of HT (P ≤ 0.05 for each comparison). In multivariate analysis, tapering was significantly associated with younger age (odds ratio [OR], 0.97; 95% CI, 0.94-0.99), initiating HT for menopausal symptoms (OR, 1.66; 95% CI, 1.06-2.62), moderate (OR, 1.67; 95% CI, 1.11-2.51) or prolonged (OR, 2.86; 95% CI, 1.76-4.65) years of HT use, use of vitamin E (OR, 1.58; 95% CI, 1.02-2.44), use of yoga (OR, 2.41; 95% CI, 1.05-5.55), and higher income (OR for income <

Does Sex Influence Immunization Status for Influenza and Pneumonia in Older Veterans

20.000/y, 0.65; 95% CI, 0.46-0.92). Separately, tapering HT was significantly associated with lower menopausal symptom scores after discontinuation (&bgr; = −0.58 ± 0.21, P = 0.01). However, tapering HT also had a significant association with resumption of hormones at a later date (OR, 2.06; 95% CI, 1.20-3.52). Conclusions: Tapering HT may lessen recurrence of menopausal symptoms after discontinuation, but some women may remain inclined to return to HT. Separately, in the Department of Veterans Affairs Healthcare System, female veterans resuming HT need providers who can discuss HT options.

Organizational Characteristics Associated with the Availability of Women's Health Clinics for Primary Care in the Veterans Health Administration

OBJECTIVES: To compare the prevalence of influenza and pneumococcal immunization rates according to sex in a national sample of older veterans in the Department of Veterans Affairs (VA) healthcare system.

Patient-Centered Mental Health Care for Female Veterans

OBJECTIVE Womens health clinics (WHCs) offering integrated primary care (PC) and gender-specific services reduce fragmentation and improve quality of care for women. Our objective was to understand organizational influences on the development of WHCs for PC delivery in Veterans Health Administration (VA) facilities. METHODS We surveyed PC directors at 219 VA facilities about the presence of separate WHCs for PC and evaluated organizational characteristics (e.g., authority, staffing, and resources) associated with their development. RESULTS One hundred thirty-three VA medical centers (61%) have established WHCs for PC. VA facilities with WHCs for PC were significantly more likely to have PC leadership distinct from subspecialty care (odds ratio = 3.62; 95% confidence interval, 1.45-9.05). Local PC staff mix, team structure, and resource characteristics were not associated with WHCs. CONCLUSIONS With the growth of women in the military and, in turn, in the VA, autonomy of PC leadership may drive VA-based innovations in womens health.