Elizabeth M. Yano

Patients' participation in medical care: effects on blood sugar control and quality of life in diabetes

To maximize disease control, patients must participate effectively in their medical care. The authors developed an intervention designed to increase the involvement of patients in medical decision making. In a 20-minute session just before the regular visit to a physician, a clinic assistant reviewed the medical record of each experimental patient with him/her, guided by a diabetes algorithm. Using systematic prompts, the assistant encouraged patients to use the information gained to negotiate medical decisions with the doctor. A randomized trial was conducted in two university hospital clinics to compare this intervention with standard educational materials in sessions of equal length. The mean pre-intervention glycosylated hemoglobin (HbA1) values were 10.6±2.1% for 33 experimental patients and 10.3±2.0% for 26 controls. After the intervention the mean levels were 9.1±1.9% in the experimental group (p<0.01) and 10.6±2.22% for controls. Analysis of audiotapes of the visits to the physician showed the experimental patients were twice as effective as controls in eliciting information from the physician. Experimental patients reported significantly fewer function limitations. The authors conclude that the intervention is feasible and that it changes patient behavior, improves blood sugar control, and decreases functional limitations.

Use of Radical Cystectomy for Patients With Invasive Bladder Cancer

BACKGROUND Evidence-based guidelines recommend radical cystectomy for patients with muscle-invasive bladder cancer. However, many patients receive alternate therapies, such as chemotherapy or radiation. We examined factors that are associated with the use of radical cystectomy for invasive bladder cancer and compared the survival outcomes of patients with invasive bladder cancer by the treatment they received. METHODS From linked Surveillance, Epidemiology, and End Results-Medicare data, we identified a cohort of 3262 Medicare beneficiaries aged 66 years or older at diagnosis with stage II muscle-invasive bladder cancer from January 1, 1992, through December 31, 2002. We examined the use of radical cystectomy with multilevel multivariable models and survival after diagnosis with the use of instrumental variable analyses. All statistical tests were two-sided. RESULTS A total of 21% of the study subjects underwent radical cystectomy. Older age at diagnosis and higher comorbidity were associated with decreased odds of receiving cystectomy (for those > or = 80 vs 66-69 years old, odds ratio [OR] = 0.10, 95% confidence interval [CI] = 0.07 to 0.14; for Charlson comorbidity index of 3 vs 0-1, OR = 0.25, 95% CI = 0.14 to 0.45). Long travel distance to an available surgeon was associated with decreased odds of receiving cystectomy (for >50 vs 0-4 miles travel distance to an available surgeon, OR = 0.60, 95% CI = 0.37 to 0.98). Overall survival was better for those who underwent cystectomy compared with those who underwent alternative treatments (for chemotherapy and/or radiation vs cystectomy, hazard ratio of death = 1.5, 95% CI = 1.3 to 1.8; for surveillance vs cystectomy, hazard ratio of death = 1.9, 95% CI = 1.6 to 2.3; 5-year adjusted survival: 42.2% [95% CI = 39.1% to 45.4%] for cystectomy; 20.7% [95% CI = 18.7% to 22.8%] for chemotherapy and/or radiation; 14.5% [95% CI = 13.0% to 16.2%] for surveillance). CONCLUSIONS Guideline-recommended care with radical cystectomy is underused for patients with muscle-invasive bladder cancer. Many bladder cancer patients whose survival outcomes might benefit with surgery are receiving alternative less salubrious treatments.

Women at war: understanding how women veterans cope with combat and military sexual trauma.

The wars in Iraq (Operation Iraqi Freedom, OIF) and Afghanistan (Operation Enduring Freedom, OEF) have engendered a growing population of US female veterans, with women now comprising 15% of active US duty military personnel. Women serving in the military come under direct fire and experience combat-related injuries and trauma, and are also often subject to in-service sexual assaults and sexual harassment. However, little is known regarding how women veterans cope with these combat and military sexual trauma experiences once they return from deployment. To better understand their experiences, we conducted semi-structured interviews with nineteen OEF/OIF women veterans between January-November 2009. Women veterans identified stressful military experiences and post-deployment reintegration problems as major stressors. Stressful military experiences included combat experiences, military sexual trauma, and separation from family. Women had varying abilities to address and manage stressors, and employed various cognitive and behavioral coping resources and processes to manage their stress.

The State of Women Veterans' Health Research

AbstractOBJECTIVE: Assess the state of women veterans’ health research. DESIGN: Systematic review of studies that pertained specifically to or included explicit information about women veterans. A narrative synthesis of studies in 4 domains/topics was conducted: Stress of military life; Health and performance of military/VA women; Health services research/quality of care; and Psychiatric conditions. MEASUREMENTS AND MAIN RESULTS: We identified 182 studies. Of these, 2 were randomized-controlled trials (RCTs) and the remainder used observational designs. Forty-five percent of studies were VA funded. We identified 77 studies pertaining to the stress of military life, of which 21 reported on sexual harassment or assault. Rates of harassment ranged from 55% to 79% and rates of sexual assault from 4.2% to 7.3% in active duty military women and 11% to 48% among women veterans. Forty-two studies concerned the health and performance of military/VA women, with 21 studies evaluating sexual assault and posttraumatic stress disorder (PTSD) and their effect on health. Fifty-nine studies assessed various aspects of health services research. Eight studies assessed quality of care and 5, patient satisfaction. Twenty-five studies assessed utilization and health care organization, and findings include that women veterans use the VA less than men, that gender-specific reasons for seeking care were common among female military and veteran personnel, that provision of gender-specific care increased women veterans’ use of VA, and that virtually all VAs have available on-site basic women’s health services. Fifty studies were classified as psychiatric; 31 of these were about the risk, prevalence, and treatment of PTSD. CONCLUSIONS: Most research on VA women’s health is descriptive in nature and has concerned PTSD, sexual harassment and assault, the utilization and organization of care, and various psychiatric conditions. Experimental studies and studies of the quality of care are rare.

To use or not to use

AbstractBACKGROUND AND OBJECTIVE: Effects of advances in Department of Veterans Affairs (VA) women’s health care on women veterans’ health care decision making are unknown. Our objective was to determine why women veterans use or do not use VA health care. DESIGN AND PARTICIPANTS: Cross-sectional survey of 2,174 women veteran VA users and VA-eligible nonusers throughout southern California and southern Nevada. MEASUREMENTS: VA utilization, attitudes toward care, and socio-demographics. RESULTS: Reasons cited for VA use included affordability (67.9%); women’s health clinic (WHC) availability (58.8%); quality of care (54.8%); and convenience (47.9%). Reasons for choosing health care in non-VA settings included having insurance (71.0%); greater convenience of non-VA care (66.9%); lack of knowledge of VA eligibility and services (48.5%); and perceived better non-VA quality (34.5%). After adjustment for sociodemographics, health characteristics, and VA priority group, knowledge deficits about VA eligibility and services and perceived worse VA care quality predicted outside health care use. VA users were less likely than non-VA users to have after-hours access to nonemergency care, but more likely to receive both general and gender-related care from the same clinic or provider, to use a WHC for gender-related care, and to consider WHC availability very important. CONCLUSIONS: Lack of information about VA, perceptions of VA quality, and inconvenience of VA care, are deterrents to VA use for many women veterans. VA WHCs may foster VA use. Educational campaigns are needed to fill the knowledge gap regarding women veterans’ VA eligibility and advances in VA quality of care, while VA managers consider solutions to after-hours access barriers.

From Understanding Health Care Provider Behavior to Improving Health Care: The Queri Framework for Quality Improvement

Basic science and health care research provide the evidence base for the scientific practice of medicine. Over the past 2 decades, as increasingly refined tools for improving health and health care have been developed, the health care community has attempted to bridge the gap between available tools and actual health care practices. This gap can be bridged only by influencing health care provider behavior. The VA Quality Enhancement Research Initiative (QUERI) is a program designed to systematically translate research findings into better health care practices, and thus better health outcomes for enrolled veterans. Integrating provider behavior research considerations and findings into each step of the QUERI process will enhance the effectiveness of the initiative. This article presents a provider behavior research framework for planning, implementing, and evaluating quality improvement interventions within QUERI.

Women and war. What physicians should know.

Most of today’s 1.7 million women veterans obtain all or most of their medical care outside the VA health care system, where their veteran status is rarely recognized or acknowledged. Several aspects of women’s military service have been associated with adverse psychologic and physical outcomes, and failure to assess women’s veteran status, their deployment status, and military trauma history could delay identifying or treating such conditions. Yet few clinicians know of women’s military history—or of military service’s impact on women’s subsequent health and well being. Because an individual’s military service may be best understood within the historical context in which it occurred, we provide a focused historical overview of women’s military contributions and their steady integration into the Armed Forces since the War for Independence. We then describe some of the medical and psychiatric conditions associated with military service.

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.

Measuring the Quality of Colorectal Cancer Screening: The Importance of Follow-Up

PurposeAs evidence mounts for effectiveness, an increasing proportion of the United States population undergoes colorectal cancer screening. However, relatively little is known about rates of follow-up after abnormal results from initial screening tests. This study examines patterns of colorectal cancer screening and follow-up within the nations largest integrated health care system: the Veterans Health Administration.MethodsWe obtained information about patients who received colorectal cancer screening in the Veterans Health Administration from an existing quality improvement program and from the Veterans Health Administrations electronic medical record. Linking these data, we analyzed receipt of screening and follow-up testing after a positive fecal occult blood test.ResultsA total of 39,870 patients met criteria for colorectal cancer screening; of these 61 percent were screened. Screening was more likely in patients aged 70 to 80 years than in those younger or older. Female gender (relative risk, 0.92; 95 percent confidence interval, 0.9–0.95), Black race (relative risk, 0.92; 95 percent confidence interval, 0.89–0.96), lower income, and infrequent primary care visits were associated with lower likelihood of screening. Of those patients with a positive fecal occult blood test (n = 313), 59 percent received a follow-up barium enema or colonoscopy. Patient-level factors did not predict receipt of a follow-up test.ConclusionsThe Veterans Health Administration rates for colorectal cancer screening are significantly higher than the national average. However, 41 percent of patients with positive fecal occult blood tests failed to receive follow-up testing. Efforts to measure the quality of colorectal cancer screening programs should focus on the entire diagnostic process.

The Burden of Illness in the First Year Home: Do Male and Female VA Users Differ in Health Conditions and Healthcare Utilization

BACKGROUND we sought to describe gender differences in medical and mental health conditions and health care utilization among veterans who used Veterans Health Administration (VA) services in the first year after combat in Iraq and Afghanistan. METHODS this is an observational study, using VA administrative and clinical data bases, of 163,812 Operation Enduring Freedom/Operation Iraqi Freedom veterans who had enrolled in VA and who had at least one visit within 1 year of last deployment. RESULTS female veterans were slightly younger (mean age, 30 years vs. 32 for men; p <.0001), twice as likely to be African American (30% vs. 15%; p <.0001), and less likely to be married (32% vs. 49%; p < .0001). Women had more visits to primary care (2.6 vs. 2.0; p < .001) and mental health (4.0 vs. 3.6; p < .001) clinics and higher use of community care outside the VA (14% vs. 10%; p < .001). After adjustment for significant demographic differences, women were more likely to have musculoskeletal and skin disorders, mild depression, major depression, and adjustment disorders, whereas men were more likely to have ear disorders and posttraumatic stress disorder. Thirteen percent of women sought care for gynecologic examination, 10% for contraceptive counseling, and 7% for menstrual disorders. CONCLUSION female veterans had similar rates of physical conditions, but higher rates of some mental health disorders and additionally, used the VA for reproductive health needs. They also had slightly greater rates of health care service use. These findings highlight the complexity of female Veteran health care and support the development of enhanced comprehensive womens health services within the VA.