Evolution of Women's Health Care in the Veterans Administration

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Evolution of Women's Health Care in the Veterans
Administration

• Patty Hayes, Ph.D.
• Chief Consultant, Women Veterans Health
• Strategic Health Care Group
• Department of Veterans Affairs
• June 2009

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The Women Veteran Population
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Expanding Women Veteran Population

• 1.8 million living women Veterans in 2008
• 26.7 million living male Veterans in 2008
• 453,250 women Veterans enrolled in care in 2008
• 7.8 million male Vets enrolled in 2008
• Number of women Veterans enrolled in care is
  expected to grow by 33 in the next three years

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High VA Utilization by Operations Enduring
Freedom Iraqi Freedom (OEF/OIF) Women Veterans

• Over 102,126 Female Veterans served in OEF/OIF as
  of September 2008
• 44.2 of OEF/OIF women Veterans enroll
• Of those Enrolled ? 43.8 use from 2-10 visits

VA Healthcare Utilization Among 94,010 Female
OEF/OIF Veterans through 1st Qtr. FY 2008
Environmental Epidemiology Service
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Women Active Duty Service Personnel by Branch of
Service (Sept 07)
Where They Stand, Women in the Military,7th
Edition, Womens Research Education Institute,
2008
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Women Veterans Health Care

• Traditionally, Women Veterans have under-utilized
  VA Health care -- majority receive health care
  outside VA
• Utilization data indicate current models of care
  delivery present barriers to women veterans using
  VA

All market penetration 2007 All living male
veterans 22 All living women veterans
15 (255,374 users/1,744,580 living women
veterans)
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Women Veterans Are Younger

• Average age of VA users
• Female veteran 48
• Male veteran 61
• Among women veterans returning from OEF/OIF
• 85.3 are below age 40
• 58.0 are between ages 20-29

VA Healthcare Utilization Among 94,010 Female
OEF/OIF Veterans through 1st Qtr. FY 2008
Environmental Epidemiology Service
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Race/Ethnicity Demographics of Separated
Personnel Who Served in OEF/OIF
Source FY2008, Third Quarter OEF/OIF Data, Han
Kang, OPHEH
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Current Care Delivery Model Fragmented Care
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Fragmented Primary Care

• Womens general health care and gender-specific
  health care often handled separately
• 67 of VA sites provide primary care in
  multi-visit, multi-provider model primary
  care at one visit and gender-specific primary
  care at another visit
• Too few primary care physicians trained in
  womens health
• Inconvenient access to gender-specific specialty
  care
• Mental health care separate from primary care
• Heavy reliance on fee-basis care with
  inconsistent standards and high no show rates

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Gender Differences in Quality

• Quality is high compared to the private sector
• Quality challenges significant gender
  differences in clinical prevention measures and
  mental health screenings
• Most measures similar to the private sector
• Cardiac risk measures lower for women
• Some measures opposite the private sector
• Influenza immunizations lower for women than men
  in VA

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2007 Data on Quality and Delivery of Care
Office of Quality and Performance, Steven
Wright, Elizabeth Yano, Michelle Lucataro
unpublished report An Analysis of the Quality
of Care Provided to Men and Women in the VA
Health Care System July 2008
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Key Health Indicators for Women Veterans

• PTSD, hypertension, and depression were the top
  three diagnostic categories for women veterans
  treated by VA health care
• 22 percent of women screened positive for
  military sexual trauma (MST) compared to 1.2
  percent of men
• Of all OEF/OIF veterans who used VA health care
  in 2007, 16.7 of women and .8 of men screened
  positive for MST.

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Serving a Different Woman Veteran Changing the
Care Delivery Paradigm
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Todays Woman Veteran

• Clinics to serve needs of young, working women
• Access, flexibility of hours, use of technology
• Address sexual health, family planning
• Many have childcare responsibilities and
  eldercare demands
• Many are employed, difficult to get time off for
  appointments
• Adjustment and depression issues- high
  co-morbidity with physical diagnoses

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Readjustment issues

• Transitioning to home and mom role
• Differences for active duty, guard, reserve
• Attachment disruption and parenting issues
• Social supports network near military bases vs
  Guard, Reserve community based
• Transitioning active duty job roles to private
  sector a step-down for women?
• Readjustment vs PTSD Diagnosis

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Leadership Wants Actions

• President Obama
• Congress House and Senate Veteran Affairs
  Committees
• Secretary Shinseki
• Under Secretary for Health
• Reviews Underway
• General Accountability Office (GAO)
• Office of the Inspector General (OIG)
• Office of the Medical Inspector (OMI)

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Redesigning Primary Care Delivery for Women
Veterans

• Increase focus on quality of care issues and
  comprehensive longitudinal care for women
  veterans
• Raising the level of care delivered to women
  veterans within the primary care setting
• Gender-specific care IS primary care
• Moving beyond cervical cancer screening and
  mammograms

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Moving To Comprehensive Primary Care Delivery for
Women Veterans

• Defining Comprehensive Primary Care
• Availability of complete primary care from one
  primary care provider at one site.
• The primary care provider should, in the context
  of a longitudinal relationship, fulfill all
  primary care needs, including acute and chronic
  illness, gender-specific, preventive, and mental
  health care.

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Comprehensive Primary Care for Women Veterans

• Enormous undertaking by the VA
• Frame shift in the way care is delivered
• Our goal is to be a model of care for the nation
• Breaking new ground

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Understanding the Effects of Military Service on
Women
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Gulf War I Women Veterans

• 11 of deployed military personnel serving the
  Persian Gulf were women
• 71 of women reported at least one combat
  exposure
• Women reported similar rates of exposure to
  environmental agents such as diesel fuel, smoke
  from oil-well fires

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Gulf War I Women Veterans Health

• Gulf War I women had significantly more
  outpatient and inpatient visits compared to male
  veterans
• Fibromyalgia, Chronic Fatigue Syndrome and
  Dyspepsia ? found to be more common in GWI
  deployed women than in non-deployed women
• No consistent pattern of birth defects among
  offspring of male and female GW I vets
• Dept Veterans Affairs Study, 2000
• Iowa Persian Gulf Study Group, 1997
• Araneta,MR, et al,Prevalence of birth defects
  among infants of Gulf War veterans in arkasas,
  Arizona, California,Georgia, Hawaii, Iowa,
  1989-1993.Birth defects Research2003,67(4)246-26
• Doyle, P, et al, Miscarriage, stillbirth, and
  congenital malformation in the offspring of UK
  veterans of the first Gulf War. International
  Journal of Epidemiology2004 33(174-86

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Pregnancy Outcomes Gulf War I Veterans

• Data was inconclusive to support a link between
  Gulf War Service and Goldenhar Syndrome (syndrome
  of craniofacial abnormalities)
• IOM Report 2006
• Trend towards an increased risk of spontaneous
  abortions and ectopic pregnancies in deployed GW
  I veterans
• Not statistically significant
• Areneta et al. 2004
• No observed effect of Gulf War service on the
  risk of stillbirths or miscarriages
• Doyle et al 2004

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Air Force Women Study, 1997

• 88,415 women served in the Air Force during the
  Gulf War I Era
• Women deployed to the Gulf Region reported rash,
  cough, depression, unintentional weight loss,
  insomnia and memory problems more frequently than
  women deployed elsewhere
• More likely to report breast cysts and lumps and
  abnormal cervical cytology

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Birth Defects and Military Service since 1990-

• National Birth Defects Prevention Study-Case
  Controlled for over 30 Birth Defects
• No statistically significant association between
  parental (male or female parent) military service
  and increased risk for birth defects
• Tricuspid atresia exhibited fairly high but
  non-significant assoc with service, particularly
  for maternal service
• Military are presumed healthier than US
  population
• Did not control for deployment
• Langlois,PH et al Birth defects and military
  service since 1990.Military Medicine
  2009174,170-176.

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New Prospective Epidemiologic Study OEF/OIF
Veterans

• Cohort study of OEF/OIF veterans
• 60,000 soldiers including 12,000 women
• Reproductive health and gender specific
  conditions, pregnancy outcomes
• Response to stress, including traumas
• Military experiences, jobs, and exposure history

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More Data Is Needed

• Chronic urinary tract infections
• Anecdotal reports of high rates
• More chronic presentations
• Heat, poor hydration, less access to toileting
  and hygiene
• Possible exposures and toxic substance
  identification
• Injury patterns
• The effects of combat exposure on womens health-
• short and long term effects
• Reproductive outcomes

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Deployment health in women VA- DoD Collaboration

• Opportunity to discuss common issues
• Population based and individual data
• Areas of interest for VA
• Menstruation issues
• Tracking use of contraceptives
• Continuous use
• Changes in preparation of OCPs taken
• Pregnancy and pregnancy outcomes, including
  miscarriages, infertility
• Exposures
• Prosthetics for women
• Rehabilitation needs

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Summary

• Shrinking total veterans population but a rapidly
  expanding population of women veterans using VHA
  for their healthcare
• Increasing recognition of women veterans unique
  and complex health needsgear up for influx of
  younger women veterans
• Increase attention to comprehensive view of
  womens healthbeyond reproductive health issues
• Redesign primary care service delivery for women
• Prospective Epidemiologic Studies
• Post-deployment Health Collaborations

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VA Access Information

• 1-827-1000 for VA Benefits
• 1-877-222-VETS for VA Healthcare
• www.VA.gov
• Contact Patty Hayes. Ph.D
• Patricia.Hayes_at_VA.gov