VA Women’s Health Care Delivery & Quality:VA Women’s Health Care Delivery & Quality:

Effectively Integrating Women Veterans into Effectively Integrating Women Veterans into the Mindset of QUERI Stakeholdersthe Mindset of QUERI Stakeholders

National VA QUERI MeetingNational VA QUERI MeetingPhoenix, AZ Phoenix, AZ December 11, 2008 December 11, 2008

Center for the Study ofHealthcare Provider Behavior

Workshop LeadersWorkshop LeadersPatricia Hayes, PhDPatricia Hayes, PhD– Chief Consultant, Women Veterans Health Strategic Chief Consultant, Women Veterans Health Strategic

Healthcare GroupHealthcare GroupSteve Wright, PhDSteve Wright, PhD– Director of Epidemiology, VA Office of Quality & Director of Epidemiology, VA Office of Quality &

Performance (OQP)Performance (OQP)Donna Washington, MD, MPHDonna Washington, MD, MPH– Core Investigator and Staff Physician, VA Greater Los Core Investigator and Staff Physician, VA Greater Los

Angeles Healthcare SystemAngeles Healthcare SystemBecky Yano, PhD, MSPHBecky Yano, PhD, MSPH– Research Career Scientist, VA Greater Los Angeles Research Career Scientist, VA Greater Los Angeles

HSR&D Center of ExcellenceHSR&D Center of Excellence

Workshop ObjectivesWorkshop Objectives

Educate QUERI researchers and system Educate QUERI researchers and system partners about what is known about:partners about what is known about:– how women veterans use the VA, how women veterans use the VA, – their physical and mental health burdens, andtheir physical and mental health burdens, and– how VA care is organized to meet their needshow VA care is organized to meet their needsHighlight the WVHSHG’s strategic plans and Highlight the WVHSHG’s strategic plans and needs around women veterans’ QIneeds around women veterans’ QIReport on gender disparities in VA performance Report on gender disparities in VA performance measuresmeasuresDiscuss approaches to ensuring representation Discuss approaches to ensuring representation of women veterans in QUERI programsof women veterans in QUERI programs

Effectively Integrating Women Veterans into Effectively Integrating Women Veterans into the Mindset of QUERI Stakeholders:the Mindset of QUERI Stakeholders:

How Do We Get From Here to There?How Do We Get From Here to There?

Becky Yano, PhD, MSPHBecky Yano, PhD, MSPHNational VA QUERI MeetingNational VA QUERI Meeting

Phoenix, AZ Phoenix, AZ December 11, 2008 December 11, 2008

Center for the Study ofHealthcare Provider Behavior

Perceived Barriers to Integrating Perceived Barriers to Integrating Women into QUERI EffortsWomen into QUERI Efforts

Too few to effectively integrateToo few to effectively integrate– Small sample sizes Small sample sizes not enough cases to not enough cases to

analyze subgroups analyze subgroups end up wasting data end up wasting data

Difficult to recruit Difficult to recruit different utilization different utilization patterns (where are they?)patterns (where are they?)– Primary care based recruitment may miss Primary care based recruitment may miss

themthem– Women’s clinics highly variable Women’s clinics highly variable some some

comprehensive and some paps onlycomprehensive and some paps only

Perceived Barriers to Integrating Perceived Barriers to Integrating Women into QUERI EffortsWomen into QUERI Efforts

Greater dual use among women vets?Greater dual use among women vets?– Different insurance status Different insurance status more likely to more likely to

use VA and non-VA than male vetsuse VA and non-VA than male vets– Higher use of fee basis and contract care Higher use of fee basis and contract care

incomplete portrait of their careincomplete portrait of their care

Are they so different that your intervention Are they so different that your intervention doesn’t map to their needs?doesn’t map to their needs?

Women Veterans

HIV/Hep C

Diabetes

IschemicHD

MentalHealth

Stroke

CongestiveHF

Spinal CordInjury

PolytraumaSubstanceUse Disorders

• What is the prevalence by gender outside the VA?• Does age, health, dxs influence likelihood WVs are part of registry?• Would your interventions vary if women were explicitly included?

Adapting QUERI Studies/Trials for Adapting QUERI Studies/Trials for Women VeteransWomen Veterans

Mental Health QUERIMental Health QUERI– Women’s mental health clinics (RRP)Women’s mental health clinics (RRP)– Women’s Health TIDES?Women’s Health TIDES?

HIV/Hepatitis QUERIHIV/Hepatitis QUERI– HIV screening in women’s clinics?HIV screening in women’s clinics?

Spinal Cord Injury QUERISpinal Cord Injury QUERI

Adapting QUERI Studies/Trials for Adapting QUERI Studies/Trials for Women VeteransWomen Veterans

Congestive Heart Failure QUERICongestive Heart Failure QUERI

Diabetes QUERIDiabetes QUERI

Ischemic Heart Disease QUERIIschemic Heart Disease QUERI

Adapting QUERI Studies/Trials for Adapting QUERI Studies/Trials for Women VeteransWomen Veterans

Stroke QUERIStroke QUERI

Substance Use Disorders QUERISubstance Use Disorders QUERI

Polytrauma QUERIPolytrauma QUERI

Gender DisparitiesGender Disparities

Any evidence of gender disparities in each Any evidence of gender disparities in each QUERI?QUERI?– VA EPRP measures suggest work needed inVA EPRP measures suggest work needed in

Diabetes QUERIDiabetes QUERIMental Health QUERIMental Health QUERIOthers?Others?

– Other evidence of gender differences in Other evidence of gender differences in access to, use, costs, quality of care?access to, use, costs, quality of care?

Hypotheses about DifferencesHypotheses about Differences

Why do you think we are seeing these Why do you think we are seeing these differences in VA quality of care for differences in VA quality of care for women?women?

Going Beyond QUERI CentersGoing Beyond QUERI Centers

How to accelerate building evidence base How to accelerate building evidence base and implementing QI interventions?and implementing QI interventions?– Top WH conditions differ from those of menTop WH conditions differ from those of men– Can QUERI Centers and/or individual Can QUERI Centers and/or individual

researchers take these issues on?researchers take these issues on?ExEx: Partner Mental Health QUERI x National : Partner Mental Health QUERI x National Centers for PTSD Centers for PTSD QI for PTSD/MST for WVs QI for PTSD/MST for WVsExEx: Less breast conserving surgery in VA vs. : Less breast conserving surgery in VA vs. private sector private sector how apply QUERI methods to how apply QUERI methods to investigate, identify determinants and remedy?investigate, identify determinants and remedy?

Technical SupportTechnical Support

What kind of information/support do you What kind of information/support do you need in order to integrate women veterans need in order to integrate women veterans into your portfolio?into your portfolio?– Organizational variations in care?Organizational variations in care?– Patterns of utilization?Patterns of utilization?– Local women’s health program manager Local women’s health program manager

contacts?contacts?– Clinical, health status, demographic data?Clinical, health status, demographic data?

Sources of Collaboration to Sources of Collaboration to Leverage QUERI EffortsLeverage QUERI Efforts

Women Veterans Health Strategic Healthcare Women Veterans Health Strategic Healthcare Group as partnerGroup as partnerWomen Veteran Program Managers (dedicated Women Veteran Program Managers (dedicated FTEE/VA facility with WH expertise)FTEE/VA facility with WH expertise)Women’s Health Fellowship Program sitesWomen’s Health Fellowship Program sitesWomen’s Health Clinical Centers of Excellence Women’s Health Clinical Centers of Excellence (e.g., Palo Alto)(e.g., Palo Alto)Consortium of VA-based women’s health Consortium of VA-based women’s health researchersresearchers

2 new VAMC’s (90,000 PC Patients)

9 New VAMC’s (90,000 PC Patients)

2 New VAMC’s (40,000 PC Patients)

2 New VAMC’s (40,000 PC Patients)

ReTIDES Spread

Active VA Women’s Health Researchers

4 DCMs

2 DCMs

8 DCMs

2 DCMs

VA Women’s Health Researchers

WASHINGTONBEAN-MAYBERRY

YANOVA Greater LA

FRAYNETIMKO

VA Palo Alto

KIMERLINGNational Center

for PTSD

BASTIANCHIREAU

VA Durham

SHIPHERDRESICKVOGT

SEAVERVA Boston

SCHNURRVA White

River Junction

VERNONUniv Texas

WEISMANPenn State

LUTHERVA Gainesville

SADLERVA Iowa City

MURDOCHPOLUSNYENSRUD

VA Minneapolis

MAGRUDERVA Charleston

BRADLEYHAMMOND

KLUTEVA Puget Sound

BRADLEYVA Roseburg

YEEVA Albuquerque

KRESSINVA Bedford

SAMBAMOORTHITSENG, POGACH

VA East Orange

SURISDallas VA

McNEILBORRERA

VA Pittsburgh

WEAVERLA VELAHines VA

BOOTHVA Little Rock

KREINVA Ann Arbor

HASKELLBRANDTJUSTICEMADDOX

VA West Haven

Questions ?Questions ?

More VA Women’s Health Care More VA Women’s Health Care Research Has Been FundedResearch Has Been Funded

Impact of practice structure on quality of care Impact of practice structure on quality of care for women veteransfor women veterans (Yano)(Yano)

Gender equity in VA qualityGender equity in VA quality (Bean-Mayberry) (Bean-Mayberry)

Chronic physical and mental illness care in Chronic physical and mental illness care in women veteranswomen veterans (Sambamoorthi)(Sambamoorthi)

Quality of breast cancer care in VAQuality of breast cancer care in VA (Luther)(Luther)

Fragmentation of care and unmet health care Fragmentation of care and unmet health care needsneeds (Washington) (Washington)

Determinants of changes in how VA women’s Determinants of changes in how VA women’s health care is organizedhealth care is organized (Yano)(Yano)

More VA Women’s Health Care More VA Women’s Health Care Research on OIF/OEF FundedResearch on OIF/OEF Funded

Sexual violence and Sexual violence and gynecologic healthgynecologic health (Sadler) (Sadler)

Evaluation of MST Evaluation of MST screening/treatmentscreening/treatment (Kimerling)(Kimerling)

MST effects on PTSD and MST effects on PTSD and behavior among Marinesbehavior among Marines (Shipherd)(Shipherd)

Physical and sexual assault Physical and sexual assault in deployed women: risks, in deployed women: risks, outcomes, servicesoutcomes, services (Sadler)(Sadler)

Stigma, gender and other Stigma, gender and other barriers to VA care barriers to VA care (Vogt)(Vogt)

Brief Research HighlightsBrief Research Highlights

New systematic literature review fundedNew systematic literature review funded– Focus on women veterans’ research has Focus on women veterans’ research has

created a virtual “explosion” of new studies created a virtual “explosion” of new studies and new published resultsand new published results

– VA HSR&D funded an update of the review VA HSR&D funded an update of the review done in 2004 (published in done in 2004 (published in Journal of General Journal of General Internal MedicineInternal Medicine in 2006) in 2006)

– Bevanne Bean-Mayberry, MD (PI) (GLA)Bevanne Bean-Mayberry, MD (PI) (GLA)

New Women Veterans Cohort StudyNew Women Veterans Cohort StudyWomen’s Healthcare Evaluation of Resource Women’s Healthcare Evaluation of Resource Utilization and Outcomes Assessment (HERA)Utilization and Outcomes Assessment (HERA)OIF/OEF women veterans with matched menOIF/OEF women veterans with matched men– West Haven, CT and Indianapolis, IN initial cohortsWest Haven, CT and Indianapolis, IN initial cohorts– Obtained additional resources to add other sites (e.g., Los Obtained additional resources to add other sites (e.g., Los

Angeles, Tampa)Angeles, Tampa)Assess health care utilization, costs and satisfaction 2 Assess health care utilization, costs and satisfaction 2 years after discharge and after 2-year coverage endsyears after discharge and after 2-year coverage endsCompare diagnosis/treatment of stress associated Compare diagnosis/treatment of stress associated conditions during 2-year coverage period conditions during 2-year coverage period

Source: Brandt, Haskell, Justice et al (2008-2011) VA West Haven

National Survey of Women VeteransNational Survey of Women Veterans

New national survey funded by WVHSHG New national survey funded by WVHSHG Objectives of new national survey are to:Objectives of new national survey are to:– Identify current demographics, health care needs, and Identify current demographics, health care needs, and

VA experiences of women veteransVA experiences of women veterans– Determine how health care needs and barriers to VA Determine how health care needs and barriers to VA

health care use differ among women veterans of health care use differ among women veterans of different periods of military services (e.g., OEF/OIF different periods of military services (e.g., OEF/OIF vs. earlier periods)vs. earlier periods)

– Assess women veterans’ preferences for and Assess women veterans’ preferences for and perceived value of different types of VA interventions perceived value of different types of VA interventions to improve access and qualityto improve access and quality

From 2,500 to 3,200 will be surveyed across USFrom 2,500 to 3,200 will be surveyed across US– Equal numbers of VA users and non-usersEqual numbers of VA users and non-users

Source: Washington (2007-09) (GLA)

National Survey of VeteransNational Survey of Veterans

Public law dictates decennial survey of veterans Public law dictates decennial survey of veterans nationwidenationwideContract for 2010 survey funded to WestatContract for 2010 survey funded to WestatFunded to oversample women veteransFunded to oversample women veteransFocus on outreach/education and issues of Focus on outreach/education and issues of employability/transitionsemployability/transitions

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# Women's Clinics

# Women Veterans

Evolution of VA Women’s Health Clinics

WV Health Program Act(P.L. 102-585)

Comprehensive Women’sHealth Centers Funded

Gulf War OEF*

OIF*

GAOReport

Source: Yano EM, et al. Diffusion of VA women’s health clinics. Women’s Health Issues. 2006.

GAO Report

GAO Report

WHC mandateto “preferred”

Legislated WH service expansion