Center for the Study of Healthcare Provider Behavior A Systematic Review of the Literature on Women Veterans’ Health 2004-2008 Bevanne Bean-Mayberry MD,

Center for the Study Center for the Study of Healthcare of Healthcare Provider BehaviorProvider Behavior

A Systematic Review of the Literature A Systematic Review of the Literature on Women Veterans’ Health on Women Veterans’ Health

2004-20082004-2008

Bevanne Bean-Mayberry MD, MHS,Bevanne Bean-Mayberry MD, MHS,

Caroline Goldzweig MD, MSPH, Donna Washington MD, MPH, Caroline Goldzweig MD, MSPH, Donna Washington MD, MPH,

Elizabeth Yano PhD, MSPH, Fatma Batuman MD, Elizabeth Yano PhD, MSPH, Fatma Batuman MD,

Christine Huang MD, Isomi Miake-Lye BA, and Paul Shekelle MD, PhD Christine Huang MD, Isomi Miake-Lye BA, and Paul Shekelle MD, PhD July 15, 2010July 15, 2010


Background: Women in VABackground: Women in VA

WomenWomen

Play an increasing role in military and veteran Play an increasing role in military and veteran activities representing:activities representing:– 20% of new recruits20% of new recruits– 17% of reserve and guard forces17% of reserve and guard forces– 15% of active duty forces15% of active duty forces

Represent one of the fastest growing groups of new Represent one of the fastest growing groups of new VA healthcare users VA healthcare users

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Why Do A Systematic Review?Why Do A Systematic Review?

Women’s military experiences & responses to their experiences Women’s military experiences & responses to their experiences are often unknown or distinct from menare often unknown or distinct from men

The impact of those experiences on health status and The impact of those experiences on health status and healthcare needs is important for care deliveryhealthcare needs is important for care delivery

Systematic reviews of research evidence can inform health Systematic reviews of research evidence can inform health care decisions made by managers and policymakerscare decisions made by managers and policymakers

5 years ago, 1st ever synthesis of the scientific literature on 5 years ago, 1st ever synthesis of the scientific literature on women veterans’ health was conducted (Goldzweig et al 2006)women veterans’ health was conducted (Goldzweig et al 2006)

Since then, rapid expansion of WH research occurred in VASince then, rapid expansion of WH research occurred in VA

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Objectives Objectives

To systematically assess the recent To systematically assess the recent literature on women veterans’ health and literature on women veterans’ health and categorize the literature into key themescategorize the literature into key themes

To identify gaps in the recent literature to To identify gaps in the recent literature to be addressed by future research and be addressed by future research and policy effortspolicy efforts

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MethodsMethods

Searched multiple scientific databasesSearched multiple scientific databases– MEDLINE, PsychINFO, World CatMEDLINE, PsychINFO, World Cat– search terms search terms womenwomen and and veteransveterans

Expert VA and DOD ContactsExpert VA and DOD Contacts

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MethodsMethods

Title screen of all articles by team consensusTitle screen of all articles by team consensus

Full screen of articles by 2 WH physicians Full screen of articles by 2 WH physicians using set criteriausing set criteria

Each article summarized using standard Each article summarized using standard abstract form and categorized into evidence abstract form and categorized into evidence tables tables

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Methods: Screening Criteria Methods: Screening Criteria

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Study meets criterion A, plus B, or C, or D:

A) Study relates to US veterans or military

B) Study includes women veterans, compares men and women, or analyzes women separately

C) Study involves active duty military females and involves a health condition or functional status that requires medical intervention

D) Topic is relevant to VA healthcare or how VA care is delivered to women

Center for the Study Center for the Study of Healthcare of Healthcare Provider BehaviorProvider Behavior 88

295Rejected

At Title Screen

185Rejected

Using Criteria


Acceleration of Women Veteran Acceleration of Women Veteran Literature over Time Literature over Time

99

JGIM Special Issue 2006contributed to the increase

More articles were identified in 2004-2008 than in the previous 25 years years


Women Veteran Literature Women Veteran Literature Characteristics & VA Funding Characteristics & VA Funding

Articles Reviewed 1978-2004 (N=182) 2004-2008 (N=191)

Type of Study

- Observational 147(81%) 166(87%)

- Descriptive 22(12%) 13(7%)

-Qualitative 7(4%) 9(5%)

- Systematic Review 4(2%) 1(1%)

- Experimental 2(1%) 3(2%)

Type of Funding*

- VA 82(45%) 113(59%)

-DOD n/a 31(16%)

1010

*not mutually exclusive


Key Areas in Published Key Areas in Published Women Veteran LiteratureWomen Veteran Literature

Category N*

Deployment and Post Deployment Health 33

Organizational Research 7

Quality of Care and Patient Satisfaction 46

Access to Care and Utilization 45

Psychiatric Conditions 84

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*Not mutually exclusive


Results: Deployment HealthResults: Deployment Health

Subject Area Key Findings

Reproductive Health Reproductive problems were common among deployed OEF/OIF women

Frequent issues included pregnancy, UTI, menstrual or pap smear abnormalities

Pregnant women with deployed partners or on active duty or with >1 child had higher stress levels

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Results: Deployment Health Results: Deployment Health

Subject Area Key Findings:

Mental Health High rates of +PTSD screens and MH symptoms occur

Compared to men, women returning from duty, are more likely to screen positive

Assault history prior to combat doubled rate of new onset PTSD symptoms in women and men

Multiple deployments contribute to + MH symptoms

Psychiatric evacuations from combat theatre were common; women were overrepresented

Social support appeared protective for women’s MH

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Results: Organizational Research Results: Organizational Research

Key Findings:Key Findings:

Presence of a gynecologist in VA or a separate Presence of a gynecologist in VA or a separate gynecology or women’s clinic is associated withgynecology or women’s clinic is associated with- IUD availabilityIUD availability- advanced gynecologic proceduresadvanced gynecologic procedures- emergency gynecology services after hoursemergency gynecology services after hours

Organizational culture and leadership had positive effect Organizational culture and leadership had positive effect – Practice environment for MST* providersPractice environment for MST* providers– Presence of separate WH clinic in primary carePresence of separate WH clinic in primary care

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*MST – Military Sexual Trauma


Results: Quality of Care Results: Quality of Care


Satisfaction - outpatient satisfaction impacted by access to Satisfaction - outpatient satisfaction impacted by access to female providers, gynecology care, women’s clinicfemale providers, gynecology care, women’s clinic

Quality of care measures are similar to men, but are low Quality of care measures are similar to men, but are low for LDL control, HTN control, and immunization for LDL control, HTN control, and immunization

CV disorders more common among women veterans CV disorders more common among women veterans compared to civilian womencompared to civilian women

Urological problems are common and hormonal Urological problems are common and hormonal contraception needs are high in military womencontraception needs are high in military women

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Results: Access & UtilizationResults: Access & UtilizationKey Findings:Key Findings:

Limited access or use was associated knowledge gaps Limited access or use was associated knowledge gaps about VA care and incorrect informationabout VA care and incorrect information

Dual use (VA & non-VA care) was lower Dual use (VA & non-VA care) was lower – when gynecology care or women’s clinics were presentwhen gynecology care or women’s clinics were present– among Medicare eligible veteran women vs. menamong Medicare eligible veteran women vs. men

Women with positive screens for MH disorders, trauma, or Women with positive screens for MH disorders, trauma, or other diagnoses tend to use more healthcare services than other diagnoses tend to use more healthcare services than women without positive MH screens or men veteranswomen without positive MH screens or men veterans

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Results: Psychiatric ConditionsResults: Psychiatric Conditions


Support strong association between PTSD and MSTSupport strong association between PTSD and MST

Negative health effects from both diagnosesNegative health effects from both diagnoses

Women with trauma history report anxiety for invasive Women with trauma history report anxiety for invasive exams and male providersexams and male providers

A few studies show social support may be a factor in A few studies show social support may be a factor in resiliency and quality of life among resiliency and quality of life among

Women veterans Women veterans

Children of women veteransChildren of women veterans

While in military, pregnant, or after they transition homeWhile in military, pregnant, or after they transition home

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Building Knowledge….Prior GapsBuilding Knowledge….Prior Gaps

Research gaps indicated limited knowledge ofResearch gaps indicated limited knowledge ofPrevalence of chronic diseasesPrevalence of chronic diseases

Preferences & self reported needsPreferences & self reported needs

Utilization patterns within/outside VAUtilization patterns within/outside VA

Transitions from military to veteran statusTransitions from military to veteran status

Quality of care women vets receive, and methods showing Quality of care women vets receive, and methods showing how to improve qualityhow to improve quality

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Source: Goldzweig et al 2006


Building Knowledge….AdvancesBuilding Knowledge….Advances

Treatment outcomes in PTSD:Treatment outcomes in PTSD:– Schnurr (2007) study is first multi-centered, randomized cooperative Schnurr (2007) study is first multi-centered, randomized cooperative

trial focused on outcomes in womentrial focused on outcomes in women– Prolonged exposure therapy gave better outcomes than standard Prolonged exposure therapy gave better outcomes than standard

carecare– Showed clinical outcomes studies on women veterans are feasibleShowed clinical outcomes studies on women veterans are feasible

Access to Care Access to Care – We know much more about barriers, perceptions, and utilization of VA We know much more about barriers, perceptions, and utilization of VA

care than ever before for building a foundation to interventionscare than ever before for building a foundation to interventions

Organizational Determinants of Quality Organizational Determinants of Quality – We understand more about how care is organized, features important We understand more about how care is organized, features important

to women, and impact of strong leadership for support of care deliveryto women, and impact of strong leadership for support of care delivery

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Ongoing Gaps…Future VA ResearchOngoing Gaps…Future VA Research

Clinical and intervention outcome studiesClinical and intervention outcome studies– for chronic mental health & physical conditionsfor chronic mental health & physical conditions

Transitions from military to civilian lifeTransitions from military to civilian life

Impact of military duty, transitions and Impact of military duty, transitions and health outcomes on military/veteran familieshealth outcomes on military/veteran families

2020


Summary Summary

Number of articles in current review (5 yrs) Number of articles in current review (5 yrs) surpassed number retrieved from prior 25 yrssurpassed number retrieved from prior 25 yrs

Growth of studies likely due to increased VA supportGrowth of studies likely due to increased VA support

Most research remains observational, Most research remains observational, butbut – Documents clear shift from descriptive to analytical focus Documents clear shift from descriptive to analytical focus

in access, utilization, quality and post-deployment health in access, utilization, quality and post-deployment health – Demonstrates 2 clinical trialsDemonstrates 2 clinical trials– Provides an evidence base for detecting barriers, defining Provides an evidence base for detecting barriers, defining

care delivery, and to begin to identify best practices care delivery, and to begin to identify best practices

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ImplicationsImplications

Areas more fully developed in women veterans’ research Areas more fully developed in women veterans’ research should serve as a foundation for future intervention and should serve as a foundation for future intervention and implementation research in VAimplementation research in VA

Substantial knowledge on women veterans’ mental health Substantial knowledge on women veterans’ mental health issues should expand issues should expand – To include studies on treatment modalities and outcomes To include studies on treatment modalities and outcomes – To explore ways in which veteran, provider or practice settings To explore ways in which veteran, provider or practice settings

can incorporate evidenced based treatments & evaluate can incorporate evidenced based treatments & evaluate outcomesoutcomes


Thank youThank you

VA Greater Los Angeles Evidence Synthesis Program & VA Greater Los Angeles Evidence Synthesis Program & Southern California/RAND Evidence-based Practice Center Southern California/RAND Evidence-based Practice Center

VA Greater Los Angeles HSR&D Center Staff VA Greater Los Angeles HSR&D Center Staff – For assistance with standardized abstractsFor assistance with standardized abstracts

VA Health Services Research &Development Service, VA Health Services Research &Development Service, Washington, DCWashington, DC

Women Veterans Health Strategic Healthcare Group Women Veterans Health Strategic Healthcare Group (WVHSHG), Washington, DC(WVHSHG), Washington, DC

The Upperman & Bean-Mayberry Family The Upperman & Bean-Mayberry Family