State of Reproductive Health In Women Veterans – VA Reproductive Health Diagnoses and Organization of Care

Reproductive health (RH) is a critical part of health. For women, RH encompasses gynecological health throughout life, preconception care, maternity care, cancer care, and the interaction of RH with other mental and medical conditions. Reproductive Health is defined as a state of complete physical, mental, and social well-be­ing and not merely the absence of reproductive disease or infirmity. This definition highlights the importance of taking a health systems approach that integrates RH care issues and services with other aspects of care needed across the life course. The RH needs of women are shaped by their stages of life and life experiences. For women Veterans, their military experiences may influence their RH in important ways. Given the increasing numbers of women in the military and women Veterans, it is critical to understand key aspects of RH in this unique population of women. This first report of the State of Reproductive Health in Women Veterans provides an overview of the RH diagnoses of women Veterans utilizing the Department of Veterans Affairs (VA) health care services, VA delivery of RH care, and a vision for RH in VA

Expanding the VA Women’s Health Practice-Based Research Network: Increasing Capacity for Equitable Representation of Women in VA Research

Background: The Veterans Affairs (VA) Women’s Health Practice-Based Research Network (WH-PBRN) facilitates multisite women’s health research through a network of partnered VA facilities and fosters bidirectional partnership of clinicians and researchers striving to improve the health and health care of women veterans. Initial WH-PBRN development was informed by pilot studies conducted at four inaugural sites. The WH-PBRN then expanded to 37 VA sites in 2012. To further grow into a more diverse network, a call for site applications went out March 2015; WH-PBRN expanded to 60 sites in June 2015. As a program evaluation activity, we examined representativeness of WH-PBRN sites (relative to VA sites nationally) before and after expansion. Methods: WH-PBRN site applications included questions about facility characteristics, including items indicating level of local research support such as presence of an affiliated Health Services Research and Development (HSR&D) center at the facility. We coupled those data with aggregated, site-level, national VA administrative data from fiscal year 2014 describing characteristics of women veteran patients using each site. Results: From pre- to post-expansion, the network grew from 37 sites, representing 146,706 women veteran outpatients, to 60 sites, representing more than half of all WV outpatients (220,465 of 391,062 women veterans nationally). Expansion successfully increased representation of diverse populations. For example, across sites, number of women veterans from a racial/ethnic minority group increased from 38% pre to 40% post. Member sites together are fairly representative of Veterans Health Administration (VHA) as a whole; for example, 43% of women veterans at the 60 WH-PBRN sites have age \u3c 45 years (vs 42% VA-wide), 22% (vs 26%) have a rural residence, 84% (vs 91%) used primary care, and 39% (vs 41%) used mental health services. The main difference is that 35% have an HSR&D center (vs 16% VA-wide). Number of Veterans Integrated Service Networks represented increased from 17 pre to 20 post, increasing geographic heterogeneity. Conclusion: WH-PBRN represents a large and geographically diverse nationwide network of 60 VA sites. Expansion increased the number and diversity of women veterans represented in the network. Across facilities, most women use primary care services, suggesting VHA primary care settings are an excellent venue for recruitment. Similarly, a large proportion receives mental health care: this is important since women’s mental health care remains a major focus of VHA research. The expanded WH-PBRN provides greater opportunity to increase equitable representation of women veterans in VA research, and to conduct health services research that examines diverse health care delivery systems

Racial/Ethnic Disparities in Mortality Across the Veterans Health Administration.

Purpose: Equal-access health care systems such as the Veterans Health Administration (VHA) reduce financial and nonfinancial barriers to care. It is unknown if such systems mitigate racial/ethnic mortality disparities, such as those well documented in the broader U.S. population. We examined racial/ethnic mortality disparities among VHA health care users, and compared racial/ethnic disparities in VHA and U.S. general populations. Methods: Linking VHA records for an October 2008 to September 2009 national VHA user cohort, and National Death Index records, we assessed all-cause, cancer, and cardiovascular-related mortality through December 2011. We calculated age-, sex-, and comorbidity-adjusted mortality hazard ratios. We computed sex-stratified, age-standardized mortality risk ratios for VHA and U.S. populations, then compared racial/ethnic disparities between the populations. Results: Among VHA users, American Indian/Alaskan Natives (AI/ANs) had higher adjusted all-cause mortality, whereas non-Hispanic Blacks had higher cause-specific mortality versus non-Hispanic Whites. Asians, Hispanics, and Native Hawaiian/Other Pacific Islanders had similar, or lower all-cause and cause-specific mortality versus non-Hispanic Whites. Mortality disparities were evident in non-Hispanic-Black men compared with non-Hispanic White men in both VHA and U.S. populations for all-cause, cardiovascular, and cancer (cause-specific) mortality, but disparities were smaller in VHA. VHA non-Hispanic Black women did not experience the all-cause and cause-specific mortality disparity present for U.S. non-Hispanic Black women. Disparities in all-cause and cancer mortality existed in VHA but not in U.S. population AI/AN men. Conclusion: Patterns in racial/ethnic disparities differed between VHA and U.S. populations, with fewer disparities within VHAs equal-access system. Equal-access health care may partially address racial/ethnic mortality disparities, but other nonhealth care factors should also be explored

Substance Use Disorder-Related Disparities in Patient Experiences of Primary Care

Purpose: To assess disparities in primary care experiences for patients with a substance use disorder (SUD) diagnosis. Methods: We assessed differences in Veterans Health Administration (VA) primary care patients' experiences using data from the 2014 outpatient VA Patient-Centered Medical Home Survey of Healthcare Experiences of Patients (SHEP; N=286,026). We obtained patient demographics and diagnoses from VA electronic medical record data. Results: Patients with an SUD diagnosis reported worse experiences for 8 of 12 SHEP measures, including access, provider communication, and information received (p<0.05). Conclusion: Targeted strategies may be needed to ensure patients with SUD have favorable primary care experiences

Racial/Ethnic Disparities in Mortality Across the Veterans Health Administration

Purpose: Equal-access health care systems such as the Veterans Health Administration (VHA) reduce financial and nonfinancial barriers to care. It is unknown if such systems mitigate racial/ethnic mortality disparities, such as those well documented in the broader U.S. population. We examined racial/ethnic mortality disparities among VHA health care users, and compared racial/ethnic disparities in VHA and U.S. general populations. Methods: Linking VHA records for an October 2008 to September 2009 national VHA user cohort, and National Death Index records, we assessed all-cause, cancer, and cardiovascular-related mortality through December 2011. We calculated age-, sex-, and comorbidity-adjusted mortality hazard ratios. We computed sex-stratified, age-standardized mortality risk ratios for VHA and U.S. populations, then compared racial/ethnic disparities between the populations. Results: Among VHA users, American Indian/Alaskan Natives (AI/ANs) had higher adjusted all-cause mortality, whereas non-Hispanic Blacks had higher cause-specific mortality versus non-Hispanic Whites. Asians, Hispanics, and Native Hawaiian/Other Pacific Islanders had similar, or lower all-cause and cause-specific mortality versus non-Hispanic Whites. Mortality disparities were evident in non-Hispanic-Black men compared with non-Hispanic White men in both VHA and U.S. populations for all-cause, cardiovascular, and cancer (cause-specific) mortality, but disparities were smaller in VHA. VHA non-Hispanic Black women did not experience the all-cause and cause-specific mortality disparity present for U.S. non-Hispanic Black women. Disparities in all-cause and cancer mortality existed in VHA but not in U.S. population AI/AN men. Conclusion: Patterns in racial/ethnic disparities differed between VHA and U.S. populations, with fewer disparities within VHAs equal-access system. Equal-access health care may partially address racial/ethnic mortality disparities, but other nonhealth care factors should also be explored

Promoting learning health system feedback loops: Experience with a VA practice-based research network card study

BackgroundWe tested the capacity of the 60-site VA Women's Health Practice-Based Research Network (WH-PBRN), embedded within VA, to employ a multisite card study to collect women Veterans' perspectives about Complementary and Integrative Health (CIH) and to rapidly return findings to participating sites and partnered national policy-makers in support of a Learning Health System (LHS) wherein evidence generation informs ongoing improvement.MethodsVA primary care clinic clerks and nurses distributed anonymous surveys (patient feedback forms) at clinics for up to two weeks in fiscal year 2017, asking about CIH behavior and preferred delivery methods. We examined the project's feasibility, representativeness, acceptability, and impact via a tracking system, national administrative data, debriefing notes, and three surveys of WH-PBRN Site Leads.ResultsTwenty geographically diverse and largely representative VA Medical Centers and 11 Community-Based Outpatient Clinics volunteered to participate. Over six months, N = 1191 women Veterans responded (median 57; range 8-151 per site). In under three months, we returned local findings benchmarked against multisite findings to all participating sites and summary findings to national VA partners. Sites and partners disseminated results to clinical and leadership stakeholders, who then applied results as warranted.ConclusionsVA effectively mobilized an embedded PBRN to implement a timely, representative, acceptable and impactful operations project.ImplicationsCard studies by PBRNs within large, national healthcare systems can provide rapid feedback to participating sites and national leaders to guide policies, programs, and practices.Level of evidenceSelf-selected respondents could have biased results