Biomedical Laboratory Research Priorities
The Biomedical Workgroup established research on sex-based influences on prevention, induction, and progression of diseases relevant to women veterans as their overarching focus. Based on current evidence of the prevalence of conditions among women veterans, the Biomedical research priorities focused on (1) mental health (especially PTSD, stress, addiction, sexual trauma, and depression), (2) military occupational hazards (focused on injury and rehabilitation, wound healing, tissue remodeling, vaccine development, and biological and chemical exposures), (3) chronic diseases (with emphasis on diabetes, infections, autoimmunity, osteoporosis, arthritis, and chronic pain), (4) cancer (focused on etiology and response to treatment for exposure-related cancers), and (5) reproductive health (including fertility, contraception, and menopausal issues).
Because many of these priorities overlap with programmatic themes of the NIH Office of Research on Women's Health, VA researchers will need to remain apprised of advances and opportunities that cross agency lines. Nonetheless, VA has unique strengths that will facilitate the advancement of novel biomedical research.
Clinical Science Research Priorities
The Clinical Science Workgroup focused on the relative paucity of reliable epidemiologic data on women veterans, spanning from risks and exposures before entry into the military, through military experience and exposures, to status after military discharge regardless of their ultimate choice of care provider (VA or not VA). While the Department of Defense (DoD) has established inception cohorts of female veterans, access to these data for the purposes of linking past exposures forward through their veteran years has been problematic. Moreover, few VA clinical studies have been conducted among women veterans, hindered mainly by the small numbers of women at individual facilities. Priority recommendations included creating data use agreements that facilitate VA researchers' access to DoD databases on military women. Barring that, creation of a prospective cohort of women upon discharge from the military (i.e., when they become veterans) should be pursued to build the necessary foundation for future VA research.
In the interim, the Clinical Sciences Workgroup identified special conditions and populations on whom VA clinical research should be focused, including (1) pregnancy and fertility issues, (2) returning military and reservists, (3) long-term care, (4) substance abuse and mental health, (5) homelessness, (6) PTSD and military sexual trauma, and (7) recent amputees.
Rehabilitation Research Priorities
The VA's Rehabilitation Research and Development (RR&D) Service spans biomedical, clinical, and health services research in service of maximizing function and quality of life (including vocational outcomes), preventing and treating secondary complications, and addressing psychosocial issues associated with disability and recovery. The Rehabilitation Workgroup established 6 priority conditions/diseases, focused on the rehabilitative aspects associated with (1) arthritis, (2) chronic pain, (3) obesity, (4) osteoporosis/fall-related injuries, (5) amputation (specifically, socket-fit technology), and (6) reproductive challenges for disabled women veterans. While some of these priorities are shared by NIH, VA's unique contributions include prosthetics (e.g., menstrual cycle/limb volume variability and socket-fit for amputees) and rehabilitation engineering (e.g., assistive technologies among women with disabilities; gender-specific technologies for urinary incontinence). Because of VA's investment in centralized administrative and clinical databases, VA researchers are also well-positioned to explore gender differences in chronic pain and obesity in relation to rehabilitation outcomes. Given the rehabilitation demands of the injuries incurred by women veterans who have served in Iraq and Afghanistan, opportunities for using merged DoD-VA data in service of research capable of improving their quality of care are being missed. They also recommended joint agency requests-for-applications (RFAs), for example, between the VA and the National Institute of Disability and Rehabilitation Research or within-VA initiatives, for example, between RR&D and the VA's Quality Enhancement Research Initiative (QUERI), leveraging resources and expertise to improve women veterans' health and health care related to disabling stages of QUERI conditions (e.g., stroke).
Health Services Research Priorities
The Health Services Workgroup focused on development of 2 targeted RFAs, 1 on evaluation of models for delivery of women veterans' health care, and another fostering needs assessment projects. The core goals for delivery model studies focused on the need to measure the quality associated with different care models serving women veterans, including, for example, evaluations by setting (e.g., large VA medical centers vs. small community-based outpatient clinics); by type of provider (e.g., among fee-basis or contract providers, same-gender providers) and to evaluate the quality, costs, access, and continuity tradeoffs women veterans face in different care settings and for different health conditions (e.g., mental health, specialty care, gender-specific services). Benchmarking VA-based access and quality to services outside the VA is also a priority to ensure equitable care provision. The Workgroup called for needs assessment for high-impact conditions, including psychiatric/emotional disorders and military-specific exposures, assessments of women veterans' needs and preferences for health services and their care environment, gender-specific barriers to access (including issues related to service connection), and better epidemiologic data on their disease burden and utilization patterns. Selected on the basis of their likely impact on health-related quality of life, high-priority conditions included the following:
- Psychiatric/emotional health
- Reproductive health/infertility/pregnancy
- Military-specific exposures
- Bone and musculoskeletal diseases
- Chronic pain
- Behavioral health (e.g., drugs, alcohol, tobacco, stress-related)
- Obesity/metabolic syndrome/diabetes
- Thyroid disorders
- Urinary incontinence
- Menstrual disorders/menopausal symptoms
- Oral health
- Eye/vision problems
Building an Infrastructure for Fostering the Conduct of VA Women's Health Research
At all stages, the need to build an effective infrastructure for fostering the conduct of VA Women's Health Research was deemed central to the success of the resulting agenda. In particular, while several pioneering VA researchers interested in exploring women veterans' health research have made significant inroads in contributing to our knowledge base over the past decade, anecdotal stories about perceived barriers to conducting, and publishing research about women veterans challenged us to ascertain their prevalence.
Conference participants were therefore asked to complete a brief barriers survey before the conference to permit time for analysis and feedback (85% response rate, n=28). VA-based Women's Health Research was roughly split between the study of nonveteran women (61%) and veteran women who used the VA (57%). (Note: Conferees could report more than 1 type of research, resulting in sums over 100%.) Over a quarter (28%) conducted research involving women veterans who do not use VA health care; only 18% had conducted research on women in the military. Only 18% had done research on biomedical samples taken from women and 14% on animal studies related to gender issues, although these figures also reflect the distribution of survey respondents (18% were biomedical researchers).
The top 5 perceived barriers to conducting VA Women's Health Research were cited as: (1) the lack of a network of VA facilities to recruit women veterans for research studies, (2) difficulty in identifying women veterans who do not use the VA, (3) lack of coordination with other agencies (e.g., DoD), (4) lack of availability of needed variables in centralized databases, and (5) low numbers of women veterans overall. These results were reported to all conference participants and provided to the Infrastructure Workgroup for discussion and suggestions for resolution.
Details for resolving each identified barrier are listed in . Central to building the needed infrastructure is the development of VA practice-based research networks akin to those cultivated by AHRQ for primary care research, but among sites with larger caseloads of women veterans to facilitate recruitment efforts. Considerable education of the field (i.e., reviewers, investigators, non-VA research partners) is also needed to publicize the opportunities and demand for more VA Women's Health Research, as well as solutions to some of the methodologic challenges, such as the Institute of Medicine's brief on small sample size methods and their role in advancing research. The value of and potential role for inter-agency collaborations is substantial, for example, with DoD to conduct longitudinal research that builds on military cohorts, and with the National Center for Health Statistics to integrate veteran status into national surveys, as AHRQ does in the Medical Expenditure Panel Survey. Finally, backing the agenda with new funding is key. VA HSR&D Service has already published a new Women's Health solicitation, while planning grants, pilot funds, and administrative supplements to add women (or female specimens) to existing studies were proposed to accelerate and promote greater inclusion of women.
Improving the Infrastructure for Enhancing VA Women's Health Research
Building a consortium of researchers committed to women veterans' health research within VA and through university and other partnerships is a crucial next step. The agenda-setting conference was an important first step in this regard, building on existing ties across VA and non-VA organizations and creating new ones. The VA research website has already fostered new collaborations and mentoring relationships, while providing access to a searchable database of VA investigators, funded studies and publications. Access to VA datasets has been enhanced through data use agreements and technical consultation with 1 or more VA resource centers, such as the VA Information Resource and Education Center. While leading VA-funded research still requires a 5/8th VA appointment, non-VA researchers commonly collaborate with VA-based researchers, capitalizing on special expertise and common interests to pursue a broad range of research studies, whereas other agencies (e.g., National Cancer Institute) also fund women veterans' research, providing additional venues for non-VA researchers to directly contribute to this growing field.