Many lesbian and bisexual (LB) women veterans may have been targets of victimization in the military based on their gender and presumed sexual orientation, and yet little is known regarding the health or mental health of LB veterans, nor the degree to which they feel comfortable receiving care in the VA.
The purpose of this study was to examine the prevalence of mental health and gender-specific conditions, VA healthcare satisfaction and trauma exposure among LB veterans receiving VA care compared with heterosexually-identified women veterans receiving.
Prospective cohort study of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) women veterans at two large VA facilities.
Three hundred and sixty five women veterans that completed a baseline survey. Thirty-five veterans (9.6 %) identified as gay or lesbian (4.7 %), or bisexual (4.9 %).
Measures included sexual orientation, military sexual trauma, mental and gender-specific health diagnoses, and VA healthcare utilization and satisfaction.
LB OEF/OIF veterans were significantly more likely to have experienced both military and childhood sexual trauma than heterosexual women (MST: 31 % vs. 13 %, p < .001; childhood sexual trauma: 60 % vs. 36 %, p = .01), to be hazardous drinkers (32 % vs. 16 %, p = .03) and rate their current mental health as worse than before deployment (35 % vs. 16 %, p < .001).
Many LB veterans have experienced sexual victimization, both within the military and as children, and struggle with substance abuse and poor mental health. Health care providers working with female Veterans should be aware of high rates of military sexual trauma and childhood abuse and refer women to appropriate VA treatment and support groups for sequelae of these experiences. Future research should focus on expanding this study to include a larger and more diverse sample of lesbian, gay, bisexual, and transgender veterans receiving care at VA facilities across the country.
lesbian; health services research; Veterans; women
The 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.
To identify healthcare delivery preferences and healthcare use of WVs by military service era to inform program design and patient-centeredness.
DESIGN AND PARTICIPANTS
Cross-sectional 2008–2009 survey of a nationally representative sample of 3,611 WVs, weighted to the population.
Healthcare 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.
Military 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.
Our 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.
women Veterans; VA healthcare; health services need; health services utilization; health care preferences
More women are using Veterans’ Health Administration (VHA) Emergency Departments (EDs), yet VHA ED capacities to meet the needs of women are unknown.
We assessed VHA ED resources and processes for conditions specific to, or more common in, women Veterans.
Cross-sectional questionnaire of the census of VHA ED directors
Resources and processes in place for gynecologic, obstetric, sexual assault and mental health care, as well as patient privacy features, stratified by ED characteristics.
All 120 VHA EDs completed the questionnaire. Approximately nine out of ten EDs reported having gynecologic examination tables within their EDs, 24/7 access to specula, and Gonorrhea/Chlamydia DNA probes. All EDs reported 24/7 access to pregnancy testing. Fewer than two-fifths of EDs reported having radiologist review of pelvic ultrasound images available 24/7; one-third reported having emergent consultations from gynecologists available 24/7. Written transfer policies specific to gynecologic and obstetric emergencies were reported as available in fewer than half of EDs. Most EDs reported having emergency contraception 24/7; however, only approximately half reported having Rho(D) Immunoglobulin available 24/7. Templated triage notes and standing orders relevant to gynecologic conditions were reported as uncommon. Consistent with VHA policy, most EDs reported obtaining care for victims of sexual assault by transferring them to another institution. Most EDs reported having some access to private medical and mental health rooms. Resources and processes were found to be more available in EDs with more encounters by women, more ED staffed beds, and that were located in more complex facilities in metropolitan areas.
Although most VHA EDs have resources and processes needed for delivering emergency care to women Veterans, some gaps exist. Studies in non-VA EDs are required for comparison. Creative solutions are needed to ensure that women presenting to VHA EDs receive efficient, timely, and consistently high-quality care.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2327-7) contains supplementary material, which is available to authorized users.
veterans’ health; women’s health; emergency medicine; organization of care
With the increasing number of women Veterans enrolling in the Veterans Health Administration (VA), there is growing demand for reproductive health services. Little is known regarding the on-site availability of reproductive health services at VA and how this varies by site location and type.
To describe the on-site availability of hormonal contraception, intrauterine device (IUD) placement, infertility evaluation or treatment, and prenatal care by site location and type; the characteristics of sites providing these services; and to determine whether, within this context, site location and type is associated with on-site availability of these reproductive health services.
We used data from the 2007 Veterans Health Administration Survey of Women Veterans Health Programs and Practices, a national census of VA sites serving 300 or more women Veterans assessing practice structure and provision of care for women. Hierarchical models were used to test whether site location and type (metropolitan hospital-based clinic, non-metropolitan hospital-based clinic, metropolitan community-based outpatient clinic [CBOC]) were associated with availability of IUD placement and infertility evaluation/treatment. Non-metropolitan CBOCs were excluded from this analysis (n = 2).
Of 193 sites, 182 (94 %) offered on-site hormonal contraception, 97 (50 %) offered on-site IUD placement, 57 (30 %) offered on-site infertility evaluation/treatment, and 11 (6 %) offered on-site prenatal care. After adjustment, compared with metropolitan hospital based-clinics, metropolitan CBOCs were less likely to offer on-site IUD placement (OR 0.33; 95 % CI 0.14, 0.74).
Compared with metropolitan hospital-based clinics, metropolitan CBOCs offer fewer specialized reproductive health services on-site. Additional research is needed regarding delivery of specialized reproductive health care services for women Veterans in CBOCs and clinics in non-metropolitan areas.
women veterans; reproductive health; reproductive health services; Department of Veterans Affairs
Heart disease is the leading cause of death for women in the United States, accounting for 24.5 % of all deaths among women. Earlier research has demonstrated racial/ethnic differences in prevalence of cardiovascular (CVD) risk factors.
To empirically examine the prevalence of CVD risk factors among a national sample of women Veterans by race/ethnicity, providing the first portrait of women Veterans’ cardiovascular care needs.
DESIGN AND PARTICIPANTS
Cross-sectional, national population-based telephone survey of 3,611 women Veterans.
Women Veterans were queried about presence of diabetes, hypertension, obesity, tobacco use and physical activity. Four racial/ethnic categories were created: Hispanic, Non-Hispanic White (White), Non-Hispanic Black (Black), and Other. Logistic regressions were conducted for each risk factor to test for racial/ethnic differences, controlling for age (under 40 vs. 40 and over).
Racial/ethnic differences in CVD risk factors persisted after adjusting for age. Black women Veterans were more likely to report a diagnosis of diabetes (OR: 2.58, 95 % CI: 1.07, 6.21) or hypertension (OR: 2.31, 95 % CI: 1.10, 4.83) and be obese (OR: 2.06, 95 % CI: 1.05, 3.91) than White women Veterans. Hispanic women Veterans were more likely than White women Veterans to report diabetes (OR: 4.20, 95 % CI: 1.15, 15.39) and daily smoking (OR: 3.38, 95 % CI: 1.01, 11.30), but less likely to report a hypertension diagnosis (OR 0.21, 95% CI: 0.07, 0.64) or to be obese (OR: 0.39, 95 % CI: 0.18, 0.81).
Among women Veterans, CVD risks vary by race/ethnicity. Black women Veterans consistently face higher CVD risk compared to White women Veterans, while results are mixed for Hispanic women Veterans.
cardiovascular disease; risk factors; race; ethnicity; women veterans
Although guidelines recommend against prostate-specific antigen (PSA) screening in elderly men with limited life expectancy, screening is common.
We sought to identify medical center characteristics associated with screening in this population.
We conducted a prospective study of 622,262 screen-eligible men aged 70+ seen at 104 VA medical centers in 2003.
Primary outcome was the percentage of men at each center who received PSA screening in 2003, based on VA data and Medicare claims. Men were stratified into life expectancy groups ranging from favorable (age 70–79 with Charlson score = 0) to limited (age 85+ with Charlson score ≥1 or age 70+ with Charlson score ≥4). Medical center characteristics were obtained from the 1999–2000 VA Survey of Primary Care Practices and publicly available VA data sources.
Among 123,223 (20%) men with limited life expectancy, 45% received PSA screening in 2003. Across 104 VAs, the PSA screening rate among men with limited life expectancy ranged from 25-79% (median 43%). Higher screening was associated with the following center characteristics: no academic affiliation (50% vs. 43%, adjusted RR = 1.14, 95% CI 1.04–1.25), a ratio of midlevel providers to physicians ≥3:4 (55% vs. 45%, adjusted RR = 1.20, 95% CI 1.09–1.32) and location in the South (49% vs. 39% in the West, adjusted RR = 1.25, 95% CI 1.12–1.40). Use of incentives and high scores on performance measures were not independently associated with screening. Within centers, the percentages of men screened with limited and favorable life expectancies were highly correlated (r = 0.90).
Substantial practice variation exists for PSA screening in older men with limited life expectancy across VAs. The high center-specific correlation of screening among men with limited and favorable life expectancies indicates that PSA screening is poorly targeted according to life expectancy.
PSA screening; regional variation; elderly; life expectancy
The promise of widespread implementation of efficacious interventions across the cancer continuum into routine practice and policy has yet to be realized. Multilevel influences, such as communities and families surrounding patients or health-care policies and organizations surrounding provider teams, may determine whether effective interventions are successfully implemented. Greater recognition of the importance of these influences in advancing (or hindering) the impact of single-level interventions has motivated the design and testing of multilevel interventions designed to address them. However, implementing research evidence from single- or multilevel interventions into sustainable routine practice and policy presents substantive challenges. Furthermore, relatively few multilevel interventions have been conducted along the cancer care continuum, and fewer still have been implemented, disseminated, or sustained in practice. The purpose of this chapter is, therefore, to illustrate and examine the concepts underlying the implementation and spread of multilevel interventions into routine practice and policy. We accomplish this goal by using a series of cancer and noncancer examples that have been successfully implemented and, in some cases, spread widely. Key concepts across these examples include the importance of phased implementation, recognizing the need for pilot testing, explicit engagement of key stakeholders within and between each intervention level; visible and consistent leadership and organizational support, including financial and human resources; better understanding of the policy context, fiscal climate, and incentives underlying implementation; explication of handoffs from researchers to accountable individuals within and across levels; ample integration of multilevel theories guiding implementation and evaluation; and strategies for long-term monitoring and sustainability.
Many patients who should be treated for depression are missed without effective routine screening in primary care (PC) settings. Yearly depression screening by PC staff is mandated in the VA, yet little is known about the expected yield from such screening when administered on a practice-wide basis.
We characterized the yield of practice-based screening in diverse PC settings, as well as the care needs of those assessed as having depression.
Baseline enrollees in a group randomized trial of implementation of collaborative care for depression.
Randomly sampled patients with a scheduled PC appointment in ten VA primary care clinics spanning five states.
PHQ-2 screening followed by the full PHQ-9 for screen positives, with standardized sociodemographic and health status questions.
Practice-based screening of 10,929 patients yielded 20.1% positive screens, 60% of whom were assessed as having probable major depression based on the PHQ-9 (11.8% of all screens) (n = 1,313). In total, 761 patients with probable major depression completed the baseline assessment. Comorbid mental illnesses (e.g., anxiety, PTSD) were highly prevalent. Medical comorbidities were substantial, including chronic lung disease, pneumonia, diabetes, heart attack, heart failure, cancer and stroke. Nearly one-third of the depressed PC patients reported recent suicidal ideation (based on the PHQ-9). Sexual dysfunction was also common (73.3%), being both longstanding (95.1% with onset >6 months) and frequently undiscussed and untreated (46.7% discussed with any health care provider in past 6 months).
Practice-wide survey-based depression screening yielded more than twice the positive-screen rate demonstrated through chart-based VA performance measures. The substantial level of comorbid physical and mental illness among PC patients precludes solo management by either PC or mental health (MH) specialists. PC practice- and provider-level guideline adherence is problematic without systems-level solutions supporting adequate MH assessment, PC treatment and, when needed, appropriate MH referral.
depression; screening; primary care; health care delivery; veterans
To evaluate the impact of a locally adapted evidence-based quality improvement (EBQI) approach to implementation of smoking cessation guidelines into routine practice.
Data Sources/Study Setting
We used patient questionnaires, practice surveys, and administrative data in Veterans Health Administration (VA) primary care practices across five southwestern states.
In a group-randomized trial of 18 VA facilities, matched on size and academic affiliation, we evaluated intervention practices’ abilities to implement evidence-based smoking cessation care following structured evidence review, local priority setting, quality improvement plan development, practice facilitation, expert feedback, and monitoring. Control practices received mailed guidelines and VA audit-feedback reports as usual care.
To represent the population of primary care-based smokers, we randomly sampled and screened 36,445 patients to identify and enroll eligible smokers at baseline (n = 1,941) and follow-up at 12 months (n = 1,080). We used computer-assisted telephone interviewing to collect smoking behavior, nicotine dependence, readiness to change, health status, and patient sociodemographics. We used practice surveys to measure structure and process changes, and administrative data to assess population utilization patterns.
Intervention practices adopted multifaceted EBQI plans, but had difficulty implementing them, ultimately focusing on smoking cessation clinic referral strategies. While attendance rates increased (p<.0001), we found no intervention effect on smoking cessation.
EBQI stimulated practices to increase smoking cessation clinic referrals and try other less evidence-based interventions that did not translate into improved quit rates at a population level.
Smoking cessation; quality of health care; veterans
Although oral hypoglycemic agents (OHAs) are an essential element of therapy for the management of type 2 diabetes, OHA adherence is often suboptimal. Pharmacists are increasingly being integrated into primary care as part of the move towards a patient-centered medical home and may have a positive influence on medication use. We examined whether the presence of pharmacists in primary care clinics was associated with higher OHA adherence.
This retrospective cohort study analyzed 280,603 diabetes patients in 196 primary care clinics within the Veterans Affairs healthcare system. Pharmacists presence, number of pharmacist full-time equivalents (FTEs), and the degree to which pharmacy services are perceived as a bottleneck in each clinic were obtained from the 2007 VA Clinical Practice Organizational Survey—Primary Care Director Module. Patient-level adherence to OHAs using medication possession ratios (MPRs) were constructed using refill data from administrative pharmacy databases after adjusting for patient characteristics. Clinic-level OHA adherence was measured as the proportion of patients with MPR >= 80%. We analyzed associations between pharmacy measures and clinic-level adherence using linear regression.
We found no significant association between pharmacist presence and clinic-level OHA adherence. However, adherence was lower in clinics where pharmacy services were perceived as a bottleneck.
Pharmacist presence, regardless of the amount of FTE, was not associated with OHA medication adherence in primary care clinics. The exact role of pharmacists in clinics needs closer examination in order to determine how to most effectively use these resources to improve patient-centered outcomes including medication adherence.
Pharmacist; Medication adherence; Diabetes mellitus; Oral hypoglycemic agent; Patient-centered medical home
Timely access to healthcare is essential to ensuring optimal health outcomes, and not surprisingly, is at the heart of healthcare reform efforts. While the Veterans Health Administration (VA) has made improved access a priority, women veterans still underutilize VA healthcare relative to men. Eliminating access disparities requires a better understanding of the barriers to care that women veterans’ experience.
We examined the association of general and veteran-specific barriers on access to healthcare among women veterans.
DESIGN AND PARTICIPANTS
Cross-sectional, population-based national telephone survey of 3,611 women veterans.
Delayed healthcare or unmet healthcare need in the prior 12 months.
Of women veterans, 19% had delayed healthcare or unmet need, with higher rates in younger age groups (36%, 29%, 16%, 7%, respectively, in 18–34, 35–49, 50–64, and 65-plus age groups; p < 0.001). Among those delaying or going without care, barriers that varied by age group were: unaffordable healthcare (63% of 18–34 versus 12% of 65-plus age groups); inability to take off from work (39% of those <50); and transportation difficulties (36% of 65-plus). Controlling for age, race/ethnicity, regular source of care, and health status, being uninsured (OR = 6.5; confidence interval [CI] 3.0–14.0), knowledge gaps about VA care (OR = 2.1; 95% CI 1.1–4.0), perception that VA providers are not gender-sensitive (OR = 2.4; CI 1.2–4.7), and military sexual assault history (OR = 2.1; CI 1.1–4.0) predicted delaying or foregoing care, whereas VA use and enrollment priority did not.
Both general and veteran-specific factors impact women veterans’ access to needed services. Many of the identified access barriers are potentially modifiable through expanded VA healthcare and social services. Health reform efforts should address these barriers for VA nonusers. Efforts are also warranted to improve women veterans’ knowledge of availability and affordability of VA healthcare, and to enhance the gender-sensitivity of this care.
access to care; women veterans; VA healthcare; health services need; health services utilization
To identify primary care practice characteristics associated with colorectal cancer (CRC) screening performance, controlling for patient-level factors.
Data Sources/Study Setting
Primary care director survey (1999–2000) of 155 VA primary care clinics linked with 38,818 eligible patients' sociodemographics, utilization, and CRC screening experience using centralized administrative and chart-review data (2001).
Practices were characterized by degrees of centralization (e.g., authority over operations, staffing, outside-practice influence); resources (e.g., sufficiency of nonphysician staffing, space, clinical support arrangements); and complexity (e.g., facility size, academic status, managed care penetration), adjusting for patient-level covariates and contextual factors.
Data Collection/Extraction Methods
Chart-based evidence of CRC screening through direct colonoscopy, sigmoidoscopy, or consecutive fecal occult blood tests, eliminating cases with documented histories of CRC, polyps, or inflammatory bowel disease.
After adjusting for sociodemographic characteristics and health care utilization, patients were significantly more likely to be screened for CRC if their primary care practices had greater autonomy over the internal structure of care delivery (p<.04), more clinical support arrangements (p < .03), and smaller size (p < .001).
Deficits in primary care clinical support arrangements and local autonomy over operational management and referral procedures are associated with significantly lower CRC screening performance. Competition with hospital resource demands may impinge on the degree of internal organization of their affiliated primary care practices.
Primary health care; colorectal cancer; prevention; quality of health care; veterans
To determine the disease burden, measured by resource utilization, of four urologic conditions among veteran users of VA health care services and to assess variations by selected socio-demographic characteristics.
We applied expert-derived diagnosis clusters to establish four patient cohorts from a population of U.S. veterans age 18 and older with at least 1 outpatient visit in a VA health care facility in Fiscal year 2001 (n=3,691,519): (1) benign prostatic hyperplasia/lower urinary tract symptoms (BPH/LUTS), (2) kidney stones (KS), (3) urinary tract infections (UTI), and (4) urinary incontinence (UI). We identified patients with qualifying diagnosis codes associated with outpatient visits in the national VA Outpatient Clinic file thereby generating case counts for each diagnostic category.
Among veteran users of VA health care services, when defined as the primary reason for the visit, the prevalence of BPH/LUTS was 4,811 per 100,000 veterans (4.8%); the prevalence of KS was 597 per 100,000 (0.6%); the prevalence of UTI was 4,265 and 1,719 per 100,000 female and male veterans, respectively (4.3% and 1.7%); and the prevalence of UI was 2,161 and 515 per 100,000 female and male veterans, respectively (2.2% and 0.5%). Prevalence of these conditions when ascertained by capturing diagnoses appearing as secondary reasons for a physician visit was much higher.
Although we expected the prevalence of urologic conditions to be high among veterans who use the VA system for care, we found the burden of urologic disease among veterans to be comparable to other national data sets. Prevalence estimates based on primary diagnosis, rather than secondary or “any” diagnosis, significantly underestimated the disease burden among veterans.
Increasingly, primary care practices include nurse practitioners (NPs) in their staffing mix to contain costs and expand primary care. To achieve these aims in U.S. Department of Veterans Affairs medical centers (VAMCs), national policy endorsed involvement of NPs as primary care (PC) providers.
To evaluate the degree to which VAMCs incorporated NPs into PC practices between 1996 and 1999, and to identify the internal and external practice environment features associated with NP use.
We surveyed 131 PC directors of all VAMCs in 1996 and 1999 to ascertain the staffing and characteristics of the PC practice and parent organization (e.g., academic affiliation, level of physician staffing, use of managed care arrangements), and drew on previously published studies and HRSA State Health Workforce Profiles to characterize each practice's regional health care environment (e.g., geographic region, state NP practice laws, state managed care penetration). Using multivariate linear regression, we evaluate the contribution of these environmental and organizational factors on the number of NPs/10,000 PC patients in 1999, controlling for the rate of NP use in 1996.
From 1996–1999, NP use increased from 75 percent to 90 percent in VA PC practices. The mean number of NPs per practice increased by about 60 percent (2.0 versus 3.2; p<.001), while the rate of NPs/10,000 PC patients trended upward (2.2 versus 2.7; p=.09). Staffing of other primary care clinicians (e.g., physicians and physician assistants per practice) remained stable, while the NP-per-physician rate increased (0.2 versus 0.4; p<.001). After multivariate adjustment, greater reliance on managed-care-oriented provider education programs (p=.02), the presence of NP training programs (p=.05), and more specialty-trained physicians/10,000 PC patients (p=.09) were associated with greater NP involvement in primary care.
Staffing models in VA PC practices have, in fact, changed, with NPs having a greater presence. However, we found substantial practice-based variations in their use, suggesting that more research is needed to better understand how they have been integrated into practice and what impact their involvement has had on the VA's ability to achieve its restructuring goals.
Nurse practitioner; primary care staffing; practice characteristics; environmental characteristics
Meta-analyses show collaborative care models (CCMs) with nurse care management are effective for improving primary care for depression. This study aimed to develop CCM approaches that could be sustained and spread within Veterans Affairs (VA). Evidence-based quality improvement (EBQI) uses QI approaches within a research/clinical partnership to redesign care. The study used EBQI methods for CCM redesign, tested the effectiveness of the locally adapted model as implemented, and assessed the contextual factors shaping intervention effectiveness.
The study intervention is EBQI as applied to CCM implementation. The study uses a cluster randomized design as a formative evaluation tool to test and improve the effectiveness of the redesign process, with seven intervention and three non-intervention VA primary care practices in five different states. The primary study outcome is patient antidepressant use. The context evaluation is descriptive and uses subgroup analysis. The primary context evaluation measure is naturalistic primary care clinician (PCC) predilection to adopt CCM.
For the randomized evaluation, trained telephone research interviewers enrolled consecutive primary care patients with major depression in the evaluation, referred enrolled patients in intervention practices to the implemented CCM, and re-surveyed at seven months.
Interviewers enrolled 288 CCM site and 258 non-CCM site patients. Enrolled intervention site patients were more likely to receive appropriate antidepressant care (66% versus 43%, p = 0.01), but showed no significant difference in symptom improvement compared to usual care. In terms of context, only 40% of enrolled patients received complete care management per protocol. PCC predilection to adopt CCM had substantial effects on patient participation, with patients belonging to early adopter clinicians completing adequate care manager follow-up significantly more often than patients of clinicians with low predilection to adopt CCM (74% versus 48%%, p = 0.003).
Depression CCM designed and implemented by primary care practices using EBQI improved antidepressant initiation. Combining QI methods with a randomized evaluation proved challenging, but enabled new insights into the process of translating research-based CCM into practice. Future research on the effects of PCC attitudes and skills on CCM results, as well as on enhancing the link between improved antidepressant use and symptom outcomes, is needed.
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.
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.
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.
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 women’s health services within the VA.
Control of viral replication through combination antiretroviral therapy (cART) improves patient health outcomes. Yet many HIV-infected patients have co-morbidities that pose social and clinical barriers to achieving viral suppression. Integration of subspecialty services into HIV primary care may overcome such barriers.
Evaluate effect of Integrated HIV Care on suppression of HIV replication.
A retrospective cohort study of HIV patients from five Veterans Affairs healthcare facilities 2000–2006.
Patients with >3 months of follow-up, sufficient baseline HIV severity, on cART.
We measured and ranked Integrated Care at the facilities. These rankings were applied to patient visits to form an index of Integrated HIV Care utilization. We evaluated effect of Integrated HIV Care utilization on likelihood of achieving viral suppression while on cART, controlling for demographic and clinical factors using survival analysis.
The 1,018 HIV-infected patients eligible for analysis had substantial barriers to responding to cART: 93% had co-morbidities with mean 3.2 co-morbidities per patient (S.D.=2.0); 52% achieved viral suppression in median 231 days (S.D.=411.6). Patients visiting clinics which offered hepatitis, psychiatric, psychological and social services in addition to HIV primary care were 3.1 times more likely to achieve viral suppression than patients visiting clinics which offered only HIV primary care (Hazard ratio=3.1, p<.001).
Patients who visited Integrated HIV Care clinics were more likely to achieve viral suppression while on cART. Future research should investigate which elements of Integrated Care are most associated with viral control and what role provider experience plays in this association.
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.
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.
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 ≥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).
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.
The Veterans Health Administration (VA) has invested significant resources in designing and implementing a comprehensive electronic health record (EHR) that supports clinical priorities. EHRs in general have been difficult to implement, with unclear cost-effectiveness. We describe VA clinical personnel interactions with and evaluations of the EHR.
As part of an evaluation of a quality improvement initiative, we interviewed 72 VA clinicians and managers using a semi-structured interview format. We conducted a qualitative analysis of interview transcripts, examining themes relating to participants' interactions with and evaluations of the VA EHR.
Participants described their perceptions of the positive and negative effects of the EHR on their clinical workflow. Although they appreciated the speed and ease of documentation that the EHR afforded, they were concerned about the time cost of using the technology and the technology's potential for detracting from interpersonal interactions.
VA personnel value EHRs' contributions to supporting communication, education, and documentation. However, participants are concerned about EHRs' potential interference with other important aspects of healthcare, such as time for clinical care and interpersonal communication with patients and colleagues. We propose that initial implementation of an EHR is one step in an iterative process of ongoing quality improvement.
While adult immunization rates in the Department of Veterans Affairs (VA) remain higher than national rates in the United States, little is known about immunizations among one of the fastest growing populations of new VA users – women.
We compared the prevalence of influenza and pneumococcal immunization rates by gender in a national sample of older veterans in the VA system.
Design and Setting
We used a retrospective, cross-sectional sample of older veterans (age 65+) in the VA healthcare system eligible for immunization in Fiscal Years 2000-2003. We performed generalized estimating equations to analyze combined chart review and administrative data to determine effect of gender on receipt of each immunization.
Current veteran VA users age 65 and older (N=48,424 patient records).
Receipt of influenza immunization and receipt of pneumococcal immunization.
Unadjusted immunization rates were higher for men compared to women for influenza (73% vs. 69%) and pneumococcal vaccine (87% vs. 83%). Adjusting for demographics, clinical co-morbidities, utilization and region, we found that women had a significantly lower odds of both influenza (OR 0.85, 95% CI 0.79, 0.92) and pneumococcal immunization (OR 0.77, 95% CI 0.71, 0.84).
Older women veterans have lower rates of immunization compared to older men veterans in VA settings. While VA remains above community levels for immunization, older women veterans will benefit from targeted efforts to increase immunization prevalence.
immunizations; preventive health services; women; veterans; elderly
Depression treatment requires close monitoring to achieve optimal, long-term control. Use of multiple sources of health care can affect coordination and continuity of treatment for depression.
To assess levels of non-Veterans Health Administration (VA) use among depressed primary care patients by service type and examine patient factors associated with non-VA use.
Cross-sectional comparison of dual and VA-only users among depressed primary care patients. Depression was defined as PHQ-9 ≥10.
Five hundred fifty depressed patients from the baseline sample of a group-randomized trial of collaborative care for depression in ten VA primary care practices.
VA and non-VA outpatient utilization for physical and emotional health problems in the prior 6 months, patient demographics, and co-morbid conditions. All measures were self-reported and obtained at the baseline interview.
Overall, 46.8% of VA depressed primary care patients utilized non-VA care. Dual users were more likely to use acute care services (emergency room or inpatient), especially for physical health problems. Dual users of physical health services had more total visits, but fewer VA visits than VA-only users, while dual users of emotional health services had fewer total and VA visits. Factors associated with dual use were urban clinic location, having other insurance coverage, and dissatisfaction with physical health care in general.
Almost half of depressed primary care patients used non-VA care, with most of their non-VA use for physical rather than emotional health problems. Care management strategies for depressed patients should include communication and coordination with non-VA providers.
dual use; depression; primary care; veterans
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.
quality improvement; disparities; implementation research; women’s health; veterans
Implementing quality improvement programs that require behavior change on the part of health care professionals and patients has proven difficult in routine care. Significant randomized trial evidence supports creating fall prevention programs for community-dwelling older adults, but adoption in routine care has been limited. Nationally-collected data indicated that our local facility could improve its performance on fall prevention in community-dwelling older people. We sought to develop a sustainable local fall prevention program, using theory to guide program development.
We planned program development to include important stakeholders within our organization. The theory-derived plan consisted of 1) an initial leadership meeting to agree on whether creating a fall prevention program was a priority for the organization, 2) focus groups with patients and health care professionals to develop ideas for the program, 3) monthly workgroup meetings with representatives from key departments to develop a blueprint for the program, 4) a second leadership meeting to confirm that the blueprint developed by the workgroup was satisfactory, and also to solicit feedback on ideas for program refinement.
The leadership and workgroup meetings occurred as planned and led to the development of a functional program. The focus groups did not occur as planned, mainly due to the complexity of obtaining research approval for focus groups. The fall prevention program uses an existing telephonic nurse advice line to 1) place outgoing calls to patients at high fall risk, 2) assess these patients' risk factors for falls, and 3) triage these patients to the appropriate services. The workgroup continues to meet monthly to monitor the progress of the program and improve it.
A theory-driven program development process has resulted in the successful initial implementation of a fall prevention program.
Collaborative care models for depression in primary care are effective and cost-effective, but difficult to spread to new sites. Translating Initiatives for Depression into Effective Solutions (TIDES) is an initiative to promote evidence-based collaborative care in the U.S. Veterans Health Administration (VHA). Social marketing applies marketing techniques to promote positive behavior change. Described in this paper, TIDES used a social marketing approach to foster national spread of collaborative care models.
TIDES social marketing approach
The approach relied on a sequential model of behavior change and explicit attention to audience segmentation. Segments included VHA national leadership, Veterans Integrated Service Network (VISN) regional leadership, facility managers, frontline providers, and veterans. TIDES communications, materials and messages targeted each segment, guided by an overall marketing plan.
Depression collaborative care based on the TIDES model was adopted by VHA as part of the new Primary Care Mental Health Initiative and associated policies. It is currently in use in more than 50 primary care practices across the United States, and continues to spread, suggesting success for its social marketing-based dissemination strategy.
Discussion and conclusion
Development, execution and evaluation of the TIDES marketing effort shows that social marketing is a promising approach for promoting implementation of evidence-based interventions in integrated healthcare systems.