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Background: Delaying needed medical care contributes to greater health risks and higher long-term medical costs. Women Veterans with complex medical and mental health needs face increased barriers to timely care access. Objectives: In a sample of women Veterans with recent engagement in Veterans Administration (VA) primary care, we aimed to compare characteristics of women Veterans who delayed care in the past 6 months with those who did not and examine factors associated with self-reported delayed care. Our study aims to inform interventions focused on eliminating health care access disparities among women Veterans. Materials and Methods: An innovation to improve women Veterans' engagement and retention in evidence-based health care for cardiovascular (CV) risk reduction (CV Toolkit) was implemented across five primary care sites within the VA. Women Veterans who were exposed to at least one CV Toolkit component participated in a mailed survey (n = 253). We used multivariate logistic regression to model factors associated with delaying care, including trust in VA providers, positive mental health screening (i.e., positive screen for either depression or anxiety), traumatic experience, self-rated health, and age. Results: Women with any mental health symptoms (odds ratio [OR] 2.42, 95% confidence interval [CI]: 1.23–4.74) and women who had experienced a traumatic event (OR 2.61, 95%CI: 1.11–6.14) were significantly more likely to report delaying care. Conclusions: Our study identified high rates of delayed care—over one-third of respondents—among women Veterans with recent primary care engagement. Mental health symptoms were the most common reported reason for delay among those who delayed care. Clinical Trial registration: NCT02991534. [ABSTRACT FROM AUTHOR]

Background: Preventive screening at the point of care can increase desired clinical outcomes. However, the impact of repeated screening for tobacco use on receiving smoking cessation treatment among women Veteran population has not been documented. Objective: To examine screening for tobacco use using clinical reminders and the association between the number of screenings and prescription for cessation treatment. Design: A retrospective analysis using data from a 5-year implementation trial for cardiovascular risk identification conducted between December 2016 and March 2020. Subjects: Women patients who had at least one primary care visit with a women's health provider during the study period at five primary care clinics in the Veterans Affairs (VA) Healthcare System. Measures: The outcome is prescription of pharmacotherapy or referral to behavioral counseling for smoking cessation on or after the screening date. The exposure is the number of screenings for tobacco use from the trial and the annual VA national clinical reminders during the study period. Results: Of 6009 eligible patients, 5788 (96.3%) were screened at least once for tobacco use over five calendar years, and 2784 of those screened (48.1%) were reported as current and former smokers. Among current and former smokers, 709 (25.5%) received a prescription and/or referral for smoking cessation. In the adjusted model, the average predicted probability of prescription and/or referral for smoking cessation was 13.7% among current and former smokers screened once over 5 years, 18.6% among screened twice, 26.5% among screened thrice, 32.9% among screened four times, and 41.7% among screened five or six times. Conclusions: Repeated screening was associated with higher predicted probabilities of being prescribed smoking cessation treatment. [ABSTRACT FROM AUTHOR]

Cardiovascular (CV) disease is the leading cause of death among women in the United States, making CV risk screening and management a women's health priority. Objectives were to elicit barriers and facilitators to CV risk identification and reduction among women veterans, and iteratively cocreate clinical tools to identify CV risk factors and promote goal-setting for lifestyle changes. We conducted three exploratory focus groups with 21 Veterans Health Administration primary care team members and piloted patient CV screeners with brief interviews with 19 patients from two Veterans Health Administration women's clinics to inform toolkit development. We then conducted two focus groups and one interview for feedback from a total of 12 staff on the proposed toolkit components. Transcripts were summarized, and a matrix analysis was used to synthesize qualitative findings. Provider-identified barriers included difficulties disseminating CV information in clinic, limited patient knowledge, and lack of organized resources for provider communication and available referrals. Women's complex health needs were notable challenges to CV risk reduction. Facilitators included having a single place to track patient CV risks (e.g., an electronic template note), a patient screening worksheet, and aids to complete referrals. Patient-identified barriers included difficulties balancing health, finances, and physical and mental health concerns. Facilitators included resources for accountability and gender-specific information about CV risks and complications. Providers requested easy, accessible tools in the electronic record with gender-specific CV data and resources linked. Patients requested lifestyle change supports, including trustworthy sources vetted by providers. Iteratively eliciting end-users' perspectives is critical to developing user-friendly, clinically relevant tools. CV risk reduction among women veterans will require multilevel tools and resources that meet providers' and women's needs. [ABSTRACT FROM AUTHOR]

Background Food insecurity has been associated with worse health outcomes in the civilian population. Male veterans of the Gulf Wars have been shown to have a higher prevalence of food insecurity than similarly situated civilians. Women veterans have more risk factors for food insecurity, relative to male veterans, yet little is known about the prevalence of food insecurity in this cohort. Methods We used the Women Veterans' Health Utilization and Experience Survey for this analysis. Our study population consisted of women veterans who had at least three primary care or women's health visits to 1 of 12 Veteran's Health Administration health care facilities from December 2013 to November 2014. Multiple logistic regression was used to examine the relationship between food insufficiency (an inadequate amount of food intake owing to a lack of money or resources), delayed/missed care, anxiety, depression, and self-reported fair to poor health, controlling for race/ethnicity, marital status, and employment status. Results The prevalence of food insufficiency among women veterans was 27.6%. Being food insufficient was associated with 16.4, 15.4, 14.9, and 12.1 percentage point increases in the probability of delayed/missed care, screening positive for anxiety, screening positive for depression, and reporting fair to poor health, respectively ( p < .05). Conclusions The prevalence of food insufficiency in this cohort was associated with delayed access to health care and worse health outcomes. Interventions addressing Veterans Administration access and health outcomes will need to examine the potential role of food insufficiency. [ABSTRACT FROM AUTHOR]

BACKGROUND: 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. OBJECTIVE: 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. MAIN MEASURES: 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. KEY RESULTS: 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. CONCLUSIONS: 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. [ABSTRACT FROM AUTHOR]

Background: 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.Objective: 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.Main Measure: Delayed healthcare or unmet healthcare need in the prior 12 months.Key Results: 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.Conclusions: 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. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To compare the prevalence of influenza and pneumococcal immunization rates according to sex in a national sample of older veterans in the Department of Veterans Affairs (VA) healthcare system. DESIGN: Retrospective, cross-sectional. SETTING: VA healthcare system. PARTICIPANTS: Current VA healthcare system users aged 65 and older eligible for immunization in fiscal years 2001 to 2003 (N=48,424 patient records). MEASUREMENTS: Generalized estimating equations were performed to analyze combined chart review and administrative data to determine effect of sex on receipt of influenza and pneumococcal immunizations. RESULTS: Unadjusted immunization rates were higher for men than women for influenza (73% vs 69%) and pneumococcal (87% vs 83%) vaccine. Adjusting for demographics, clinical comorbidities, use, and region, women had significantly lower odds of influenza (odds ratio (OR)=0.85, 95% confidence interval (CI=0.79–0.92) and pneumococcal (OR=0.77, 95% CI=0.71–0.84) immunization. CONCLUSION: Older female veterans have lower rates of immunization than older male veterans in VA settings. Although VA remains above community levels for immunization, older female veterans will benefit from targeted efforts to increase immunization prevalence. [ABSTRACT FROM AUTHOR]

Purpose: The growing presence of female veterans within the Department of Veterans Affairs (VA) health care system highlights the need to assess the quality of and access to gender-specific care for menopause. We assessed the use of hormone therapy (HT) among female veterans before and after the release of the Women's Health Initiative clinical trial results and evaluated whether the structure of women's health care services within the VA system affects the use of HT. Methods: We identified all female veterans using HT in 2001 by using the VA pharmacy benefits management database and administrative data. Subjects identified as using HT in 2001 were evaluated to determine estrogen use status in 2003 and 2004. We calculated the change in HT use over time and performed multivariate analyses to identify patient and utilization determinants of HT discontinuation. Results: In 2001, 36,222 female veterans used HT. By 2004, 23,924 (66%) had discontinued HT. Subjects who had used a VA women's clinic or were younger (40-54 years of age) were significantly less likely to discontinue HT. However, Hispanic ethnicity, African American race, and clinical diagnoses such as heart disease and mastectomy were significantly associated with discontinuation. Conclusion: Discontinuation rates in the VA system parallel those in the private sector. However, patients with any use of VA women's clinics were less likely to discontinue HT, indicating a practice setting variation that may indicate either more specific care or differential implementation of the new HT guidelines. Further research is warranted to assess whether a disparity occurs according to practice setting (or provider factors) with rapid shifts in guidelines. [ABSTRACT FROM AUTHOR]

Aims: Women's healthcare has historically been fragmented, given the artificial separation of reproductive care from general medical care. Aiming to advance new care models for delivery of comprehensive, integrated clinical care for women, two federal agencies—the U.S. Department of Health and Human Services (DHHS) and Department of Veterans Affairs (VA)—launched specialized women's health centers (WHCs). Exemplars of comprehensive service delivery, these originally federally funded centers have served as foundations for innovations in delivering comprehensive care to women in diverse practice settings. Little is known, however, about details of their organization, staffing, practice arrangements, and service availability that might inform adoption of similar models in the community. Methods: Using comparable key informant surveys, we collected organizational data from the DHHS National Centers of Excellence (CoE) ( n = 13) and the original VA comprehensive WHC's ( n = 8). We abstracted supplemental data (e.g., academic affiliation) from the 2001 American Hospital Association (AHA) survey. Results: All DHHS and VA women's health programs served urban areas, and nearly all had academic partnerships. DHHS centers had three times the average caseload as did VA centers. Preventive cancer screening and general reproductive services were uniformly available at all centers, although DHHS centers offered extensive reproductive services on-site more frequently, and VA centers more often had on-site mental healthcare. Conclusions: The DHHS and VA comprehensive WHCs share similar missions and comparable organization, education, and clinical services, demonstrating their commitment to reducing fragmented service delivery. Their common structural components present opportunities for further advancing women's quality of care across other systems of care. [ABSTRACT FROM AUTHOR]

Objective: Women's health clinics (WHCs) offering integrated primary care (PC) and gender-specific services reduce fragmentation and improve quality of care for women. Our objective was to understand organizational influences on the development of WHCs for PC delivery in Veterans Health Administration (VA) facilities. Methods: We surveyed PC directors at 219 VA facilities about the presence of separate WHCs for PC and evaluated organizational characteristics (e.g., authority, staffing, and resources) associated with their development. Results: One hundred thirty-three VA medical centers (61%) have established WHCs for PC. VA facilities with WHCs for PC were significantly more likely to have PC leadership distinct from subspecialty care (odds ratio = 3.62; 95% confidence interval, 1.45-9.05}. Local PC staff mix, team structure, and resource characteristics were not associated with WHCs. Conclusions: With the growth of women in the military and, in turn, in the VA, autonomy of PC leadership may drive VA-based innovations in women's health. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To explore the effect of race on primary care quality and satisfaction among women in the Department of Veterans Affairs (VA), METHODS: We used a mail survey to measure primary care quality and satisfaction. We focused on 4 primary care domains: patient preference for provider, interpersonal communication, accumulated knowledge, and coordination. We performed univariate analyses to compare variables by race and multiple logistic regression analysis to examine the effect of race on the probability of reporting a perfect score on each domain, while adjusting for patient characteristics and site. RESULTS: Black women were younger, unmarried, educated, of higher income, and reported female providers and gynecological care in VA more often. In regression analysis, race was not significantly associated with any primary care domain or satisfaction. Gynecological care from VA provider was associated with perfect ratings on patient preference for provider (odds ratio [OR] 2.0, 95% confidence intervals [CI] 1.3, 3.1), and satisfaction (OR 1.6, 95% CI 1.2, 2.3), while female provider was associated with interpersonal communication (OR 1.9, 95% CI 1.4, 2.6). CONCLUSIONS: While demographics and health experiences vary by race among veterans, race had no effect on primary care ratings. Future studies need to determine whether this racial equity persists in health outcomes among women veterans. [ABSTRACT FROM AUTHOR]

Background: Provider gender, provider specialty, and clinic setting affect quality of primary care delivery for women, but previous research has not examined these factors in combination. The purpose of this study is to determine whether separate or combined effects of provider gender, availability of gynecologic services from the provider, and women’s clinic setting improve patient ratings of primary care. Methods: Women veterans receiving care in women’s clinics or traditional primary care at 10 Veteran’s Affair (VA) medical centers completed a mailed questionnaire (N = 1321, 61%) rating four validated domains of primary care (preference for provider, communication, coordination, and accumulated knowledge). For each domain, summary scores were calculated and dichotomized into perfect score (maximum score) versus other. Multiple logistic regressions were used to estimate the probability of a perfect score in each domain while controlling for patient characteristics and site. Results: Female provider was significantly associated with perfect ratings for communication and coordination. Providing gynecologic care was significantly associated with perfect ratings for male and female providers. Patients who used a women’s clinic and had a female provider who gave gynecologic care had perfect or nearly perfect ratings for preference for provider, communication, and accumulated knowledge. Conclusion: Gynecologic services are linked to patient ratings of primary care separate from and in synergy with the effect of female provider. Male and female providers should consider offering routine gynecologic services or working in coordination with a setting that provides gynecologic services. Health care evaluations should assess scope of services for provider and practice. [Copyright &y& Elsevier]

Objective: To compare patient satisfaction in women's clinics (WCs) versus traditional primary care clinics (TCs).Design: Anonymous, cross-sectional mailed survey.Setting: Eight Department of Veterans Affairs (VA) medical centers in 3 states.Patients: A random sample of women stratified by site and enrollment in WC versus TC (total response rate = 61%).Measures: Overall satisfaction and gender-specific satisfaction as measured by the Primary Care Satisfaction Survey for Women (PCSSW).Analysis: We dichotomized the satisfaction scores (excellent versus all other), and compared excellent satisfaction in WCs versus TCs using logistic regression, controlling for demographics, health status, health care use, and location.Results: Women enrolled in WCs were more likely than those in TCs to report excellent overall satisfaction (odds ratio, 1.42; 95% confidence interval, 1.00 to 2.02; P = .05). Multivariate models demonstrated that receipt of care in WCs was a significant positive predictor for all 5 satisfaction domains (i.e., getting care, privacy and comfort, communication, complete care, and follow-up care) with the gender-specific satisfaction instrument (PCSSW).Conclusions: This study is the first to consistently show higher satisfaction in WCs versus TCs despite age and race differences and comparable health status. Since these WCs show better quality in terms of satisfaction, other quality indicators should be evaluated. If WCs reduce fragmentation and improve health care delivery, the model will be applicable in VA and non-VA outpatient settings. [ABSTRACT FROM AUTHOR]

Objectives: To describe the impacts of four Veterans Health Administration (VA) Quality Enhancement Research Initiative (QUERI) projects implementing an evidence‐based lifestyle intervention known as the Diabetes Prevention Program (DPP). Data Sources and Study Setting: 2012–2024 VA administrative and survey data. Study Design: This is a summary of findings and impacts from four effectiveness‐implementation projects focused on in‐person and/or online DPP across VA sites. Data Collection/Extraction Methods: Patient demographics, participation data, and key findings and impacts were summarized across reports from the VA Diabetes‐Mellitus Quality Enhancement Research Initiative (QUERI‐DM) Diabetes Prevention Program (VA DPP) Trial, QUERI‐DM Online DPP Trial, the Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER) QUERI DPP Project, and EMPOWER 2.0 QUERI Program. Principal Findings: Between 2012 and 2024, four VA QUERI studies enrolled 963 Veterans in DPP across 16 VA sites. All participants had overweight/obesity with one additional risk factor for type 2 diabetes (i.e., prediabetes, elevated risk score, or history of gestational diabetes) and 56% (N = 536) were women. In addition to enhancing the reach of and engagement in diabetes prevention services among Veterans, these projects resulted in three key impacts as follows: (1) informing the national redesign of VA MOVE! including recommendations to increase the number of MOVE! sessions and revise guidelines across 150+ VA sites, (2) enhancing the national evidence base to support online DPP delivery options with citations in national care guidelines outside VA, and (3) demonstrating the importance of gender‐tailoring of preventive care services by and for women Veterans to enhance engagement in preventive services. Conclusions: Over the past decade, the evolution of VA QUERI DPP projects increased the reach of and engagement in diabetes prevention services among Veterans, including women Veterans who have been harder to engage in lifestyle change programs in VA, and resulted in three key impacts informing type 2 diabetes and obesity prevention efforts within and outside of VA. [ABSTRACT FROM AUTHOR]

A welcoming environment may influence patient care experiences, and it may be particularly relevant for underrepresented groups, such as women veterans at Veterans Health Administration (VA) facilities where they represent only 8–10% of patients. Challenges to ensuring a welcoming environment for women veterans may include unwelcome comments from male veterans and staff or volunteers and feeling unsafe inside or outside VA facilities. We assessed associations between reports of gender-related environment of care problems and patient-reported outcomes. We merged national patient-reported outcomes from women veterans (n = 4,961) using Consumer Assessment of Health Plans & Systems Patient Centered Medical Home (CAHPS-PCMH) survey composite measures with Women Veteran Program Managers' reports of gender-related environment of care problems (n = 127, 2016–2017) at VA facilities. We performed multilevel bivariate logistic regressions to assess associations between Women Veteran Program Managers' reports of large/extreme problems and likelihood of women veterans' optimal ratings of primary care experiences (access, coordination, comprehensiveness, provider communication, and overall rating of primary care provider). We adjusted for patient-, site-, and area-level characteristics, and clustering of patients within VA facilities, and we applied design weights to address nonresponse bias in the patient data. Response rates were 40% for women veterans and 90% for Women Veteran Program Managers. Few (<15%) Women Veteran Program Managers reported large/extreme environment of care problems. Women veterans obtaining care at those sites were less likely to rate provider communication and comprehensiveness (psychosocial health assessed) as optimal. Ensuring a welcoming environment may improve women veterans' primary care experiences. [ABSTRACT FROM AUTHOR]

Background: The Diabetes Prevention Program (DPP) is a nationally disseminated lifestyle intervention shown to prevent type 2 diabetes (diabetes). However, enrollment in the program remains variable. We sought to identify patient characteristics associated with enrollment in a virtual DPP program among women Veterans to inform ongoing diabetes prevention efforts. Methods: We conducted a retrospective analysis of 2021–2024 Department of Veterans Affairs (VA) data collected through the VA Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER) 2.0 Program, an effectiveness-implementation trial to expand access to preventative health services for women Veterans. We included women meeting DPP eligibility criteria (BMI ≥ 25 kg/m2 [or ≥ 23 if Asian] with ≥ 1 risk factor for diabetes [e.g., prediabetes]) who received care at six VA sites implementing virtual DPP. We used logistic regression to examine the association between DPP enrollment and prior use of VA preventive services for weight management or diabetes prevention including the VA MOVE! clinic, Whole Health visits, nutrition visits, weight loss medications, and/or metformin. We adjusted for sociodemographic factors, comorbidities, number of DPP recruitment contacts, and site. Results: A total of 1473 women Veterans received DPP outreach. On average, their age was 53 years (range 20–96), BMI 34 kg/m2, HbA1c 5.9%, 0.7% were Asian, 44% Black, 2% Hispanic, and 44% White. In our adjusted models, prior use of VA preventative services was not significantly associated with DPP enrollment. Younger women (OR:0.97, p = 0.002) and those who received more recruitment contacts (OR:2.63, p < 0.001), were significantly more likely to enroll in DPP. Women with housing instability were significantly less likely to enroll (OR:0.44, p = 0.029). Conclusions: We found no difference in women Veterans' enrollment in DPP based on prior use of VA weight management and prevention services. Frequency of outreach by VA sites may increase engagement in lifestyle interventions. Virtual DPP may support engagement in preventive lifestyle interventions for diverse groups of women Veterans, as a first program or as a complement to other VA services. Trial registration: ClinicalTrials.gov, NCT05050266. Registered on 20 September 2021. [ABSTRACT FROM AUTHOR]

Previous studies of pregnant veterans enrolled in Department of Veterans Affairs (VA) care reveal high rates of cesarean sections among racial/ethnic minoritized groups, particularly in southern states. The purpose of this study was to better understand contributors to and veteran perceptions of maternal autonomy and racism among veterans receiving cesarean sections. We conducted semi-structured interviews to understand perceptions of maternal autonomy and racism among 27 Black, Indigenous, People of Color (BIPOC) veterans who gave birth via cesarean section using VA maternity care benefits. Our study found that a substantial proportion (67%) of veterans had previous cesarean sections, ultimately placing them at risk for subsequent cesarean sections. More than 60% of veterans with a previous cesarean section requested a labor after cesarean (LAC) but were either refused by their provider or experienced complications that led to another cesarean section. Qualitative findings revealed the following: (1) differences in treatment by veterans' race/ethnicity may reduce maternal agency, (2) many veterans felt unheard and uninformed regarding birthing decisions, (3) access to VA-paid doula care may improve maternal agency for BIPOC veterans during labor and birth, and (4) BIPOC veterans face substantial challenges related to social determinants of health. Further research should examine veterans' perceptions of racism in obstetrical care, and the possibility of VA-financed doula care to provide additional labor support to BIPOC veterans. [ABSTRACT FROM AUTHOR]

Abstract Background Despite the relatively recent Department of Veterans Affairs (VA) policy advances in providing care for veterans and their infants during the perinatal period, little information exists regarding access to prenatal care for women veterans. Currently, VA medical centers do not provide onsite pregnancy care for veterans, but pay for care from community obstetricians through the Veterans Choice Program (VCP) and related non-VA care programs. The VCP is subcontracted to two large contractors, Health Net and TriWest, to assist the VA in administering the VCP. To date, no studies have evaluated women's perceived access to prenatal care under the VCP. Objective The purpose of this study was to understand pregnant veterans' perceived access to community prenatal care through the VCP. Design The Center for Maternal and Infant Outcomes Research in Translation (COMFORT) study is a longitudinal, prospective multisite observational cohort study of pregnant and postpartum veterans at 15 VA facilities nationwide. Telephone surveys were conducted with women veterans at 20 weeks of pregnancy. We used multivariable logistic regression to examine the odds of receiving care early enough adjusted for these key factors. Measures included perceived access to early prenatal care by race, age, marital status, history of mental health conditions, urban/rural residence, and the VCP contractor (Health Net vs. TriWest). Results Overall, 519 women veterans completed the baseline pregnancy survey. A sizeable proportion of participants reported a history of mental health conditions, including depression (56.7%), anxiety disorder (45.5%), and posttraumatic stress disorder (40.5%). White veterans were more likely to report perceived timely access to prenatal care than minority veterans (66% vs. 52%; p =.0038). Veterans receiving care at Health Net facilities were more likely to report receiving prenatal care as early as desired in comparison to veterans at TriWest facilities (adjusted odds ratio, 0.48; 95% CI, 0.32–0.73), whereas veterans with a history of depression were 1.7 times more likely to report perceived delays in desired prenatal care compared with veterans without a history of depression (adjusted odds ratio, 1.65; 95% CI, 1.08–2.53). Conclusions We found that nearly one-third of women reported problems receiving early prenatal care as soon as they would have liked. Women with histories of depression and racial minorities may require additional maternity care coordination services to ensure they receive timely prenatal care. Community-based provider networks under the VCP should continue to be expanded so that pregnant veterans are able to access high-quality prenatal care in a timely manner. [ABSTRACT FROM AUTHOR]

Abstract: Background: Primary care delivery models tailored to women’s needs and preferences are associated with higher quality and satisfaction. Therefore, the U.S. Department of Veterans Affairs (VA) recommends adoption of designated providers for women in primary care clinics or women’s health centers as the optimal models for women’s primary care. We assessed women veterans’ ratings of their VA health care quality, gender-related satisfaction, gender appropriateness, and VA provider skills in treating women, in relation to primary care model at VA sites nationwide. Methods: Health care ratings were obtained from VA users in the 2008–2009 National Survey of Women Veterans. VA administrative data identified the site for each respondent’s primary care. Facility data identified the site’s primary care model for women. We conducted multilevel modeling to compare health care ratings for sites serving 300 or more women veterans who had adopted VA recommendations for women’s primary care models (adopter sites), with non-adopter sites, and with small sites serving fewer women veterans, adjusting for patient characteristics. Results: Adopter sites received higher adjusted ratings of gender-related satisfaction and perceptions of VA provider skills than non-adopter and small sites. Adopter sites also received higher adjusted ratings of gender appropriateness than small sites. Adjusted ratings of quality of care did not differ by type of site. Conclusion: VA sites with primary care models tailored to women were rated higher on most dimensions of care. Facilitating establishment of these optimal care models at other sites is one strategy for improving women veterans’ experiences with VA care. Research to identify other features of care associated with quality could inform ongoing VA quality transformation efforts. [Copyright &y& Elsevier]

Abstract: Objective: We assessed the state of women veterans’ health research by conducting a systematic review of scientific literature published from 2004 to 2008, updating a prior review spanning the history of this literature to 2004. Methods: We identified articles by searching scientific databases and contacting experts. Relevant articles were independently evaluated by two physician reviewers. We categorized 195 articles by study design, funding source, period of military service, research topic, and health condition. Results: More research was published during this 5-year review (n = 195) than in the 25 years beforehand (n = 182). The 195 studies included five trials, but only one randomized trial, a study that examined treatment outcomes for women with posttraumatic stress disorder (PTSD). The large number of articles focused on Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) soldiers’ health issues (n = 23) reflects the growing participation of women in these conflicts. High rates of positive PTSD symptoms (range, 10%–19%) and other mental health disorders were found among OEF/OIF returning military women. The recent post-deployment literature underscores the need for repeated PTSD/mental health screening in returning veterans, and points to continuity of care needs for psychiatric and gynecological problems which occur in the field. The psychiatric and access/utilization literature confirmed the positive relationship between military sexual trauma and PTSD and the associated negative health effects. Conclusion: Although most VA women’s health research remains observational, methods are evolving toward an analytical focus. Even though successes are evident in the breadth and depth of publications, remaining gaps in the literature include post-deployment readjustment for veterans/families, and quality-of-care interventions/outcomes for physical and mental conditions. [Copyright &y& Elsevier]

Presents a letter to the editor in response to the article "The clinical researcher -- an "emerging" species," by Ralph Snyderman.

Background: Patient-perpetrated sexual harassment toward staff and patients is prevalent in Veterans Affairs and other healthcare settings. However, many healthcare facilities do not have adequate systems for reporting patient-perpetrated harassment, and there is limited evidence to guide administrators in developing them. Objective: To identify expert recommendations for designing effective systems for reporting patient-perpetrated sexual harassment of staff and patients in Veterans Affairs and other healthcare settings. Design: We conducted qualitative interviews with subject matter experts in sexual harassment prevention and intervention during 2019. Participants: We used snowball sampling to recruit subject matter experts. Participants included researchers, clinicians, and administrators from Veterans Affairs/other healthcare, academic, military, and non-profit settings (n = 33). Approach: We interviewed participants via telephone using a semi-structured guide and analyzed interview data using a constant comparative approach. Key Results: Expert recommendations for designing reporting systems to address patient-perpetrated sexual harassment focused on fostering trust, encouraging reporting, and deterring harassment. Recommendations included the following: (1) promote a climate in which harassment is not tolerated; (2) take proportional, corrective actions in response to reports; (3) minimize adverse outcomes for reporting parties; (4) facilitate and simplify reporting processes; and (5) hold the reporting system accountable. Specific strategies related to each recommendation were also identified. Conclusions: This qualitative study generated initial recommendations to guide healthcare administrators and policy makers in assessing, developing, and improving systems for reporting patient-perpetrated sexual harassment toward staff and other patients. Results indicate that proactive, careful design and ongoing evaluation are essential for ensuring that reporting systems have their intended effects and mitigating the risks of inadequate systems. Additional research is needed to evaluate strategies that effectively address patient-perpetrated harassment while balancing patients' clinical needs. [ABSTRACT FROM AUTHOR]

Few studies have focused on determinants of women's ratings of care experiences in primary care. We assessed associations between availability of women's health services and women veterans' ratings of care experiences. In a cross-sectional analysis, we linked Fiscal Year (FY) 2017 (October 1, 2016, to September 30, 2017) survey data from 126 Veterans Health Administration (VA) primary care leaders to 4,254 women veterans' ratings of care from VA's Survey of Healthcare Experiences of Patients-Patient Centered Medical Home (FY 2017). The dependent variables were ratings of optimal access (appointments, information), care coordination, comprehensiveness (behavioral health assessment), patient–provider communication, and primary care provider. Key independent variables were number of women's health services 1) routinely available all weekday hours (compared with some hours or not available) and 2) available in VA general primary care vs. other arrangements. In multilevel logistic regression models, we adjusted for patient-, facility-, and area-level characteristics. A greater number of women's health services routinely available in VA primary care was associated with a higher likelihood of optimal ratings of care coordination (adjusted odds ratio [AOR], 1.06; 95% confidence interval [CI], 1.01–1.10), provider communication (AOR, 1.08; 95% CI, 1.002–1.16), and primary care provider (AOR, 1.07; 95% CI, 1.02–1.13). A greater number of services available in VA primary care was associated with a lower likelihood of optimal ratings for access (AOR, 0.94; 95% CI, 0.88–0.99). For the most part, routine availability of women's health services in VA primary care clinics enhanced women's healthcare experiences. These empirical findings offer healthcare leaders evidence-based approaches for improving women's care experiences. [ABSTRACT FROM AUTHOR]

Background: The Veterans Health Administration (VA) is the largest integrated health system in the US and provides access to comprehensive primary care. Women Veterans are the fastest growing segment of new VA users, yet little is known about the characteristics of those who routinely access VA primary care in general or by age group.Objective: Describe healthcare needs, utilization, and preferences of women Veterans who routinely use VA primary care.Participants: 1,391 women Veterans with 3+ primary care visits within the previous year in 12 VA medical centers (including General Primary Care Clinics, General Primary Care Clinics with designated space for women, and Comprehensive Women's Health Centers) in nine states.Methods: Cross-sectional survey (45% response rate) of sociodemographic characteristics, health status (including chronic disease, mental health, pain, and trauma exposure), utilization, care preferences, and satisfaction. Select utilization data were extracted from administrative data. Analyses were weighted to the population of routine users and adjusted for non-response in total and by age group.Key Results: While 43% had health coverage only through VA, 62% received all primary care in VA. In the prior year, 56% used VA mental healthcare and 78% used VA specialty care. Common physical health issues included hypertension (42%), elevated cholesterol (39%), pain (35%), and diabetes (16%). Many screened positive for PTSD (41%), anxiety (32%), and depression (27%). Chronic physical and mental health burdens varied by age. Two-thirds (62%) had experienced military sexual trauma. Respondents reported satisfaction with VA women's healthcare and preference for female providers.Conclusions: Women Veterans who routinely utilize VA primary care have significant multimorbid physical and mental health conditions and trauma histories. Meeting women Veterans' needs across the lifespan will require continued investment in woman-centered primary care, including integrated mental healthcare and emphasis on trauma-informed, age-specific care, guided by women's provider preferences. [ABSTRACT FROM AUTHOR]

Little is known about women veterans' trust in Veterans Affairs (VA) health care and what factors promote trust in VA providers. We examined provider behaviors and characteristics of women veterans associated with trust in their VA providers. We used a 2015 survey of women veterans who were routine users of primary care at 12 VA medical centers (n = 1,395). Patient trust in their VA provider was measured on a seven-item scale. We used multiple logistic regression to examine associations of patient-provider communication and gender appropriateness with complete trust in VA provider (100 [complete trust] vs. <100 [less than complete trust]), controlling for patient characteristics. On average, 39.7% of women veterans reported complete trust in their VA providers. Those with complete trust reported greater patient-provider communication and gender appropriateness of VA services than those with less-than-complete trust (all p s ≤.001). In multiple logistic regression models, higher ratings of provider communication (adjusted odds ratio, 2.37), gender-appropriate care (adjusted odds ratio, 1.93), and trauma-sensitive communication (adjusted odds ratios, 1.79–6.08) were associated with a higher likelihood of reporting complete trust in their VA provider. Women veterans reported high levels of trust in their VA providers. Provider communication, gender-appropriate care, and trauma-sensitive communication were associated with greater patient trust. Although it is important to highlight the steps already taken by VA to increase the quality of care for women veterans, current findings suggest that women veterans' trust may be further increased by interventions to improve trauma-informed care by VA providers. [ABSTRACT FROM AUTHOR]

Background: Pregnancy-related cardiovascular (CV) conditions are important predictors of future cardiovascular disease (CVD). Nontraditional factors, such as depression and chronic stress, have been associated with CVD, but their role in pregnancy-related CVD conditions (pCVD) remains unknown. To determine the association between nontraditional factors and CV conditions in pregnancy, and to explore if this risk varies by race. Methods: Using data from a prospective study of pregnant women within the veterans affairs health system (COMFORT study), we described the prevalence of nontraditional factors (e.g., depression, post-traumatic stress disorder [PTSD], chronic stress) and used logistic regression to determine the association between nontraditional factors and pregnancy-related CV conditions (pre-eclampsia/eclampsia, gestational hypertension, gestation diabetes, or preterm delivery). Analyses were then stratified by race. Results: Among 706 enrollees, 26% had pregnancy-related CV conditions. These women had significantly higher rates of depression (62% vs. 45%, p < 0.01), anxiety (50% vs. 37%, p = 0.01), PTSD (44% vs. 29%, p < 0.01), and high stress levels before pregnancy (22% vs. 16%, p = 0.05) compared with women with normal pregnancies. Overall, these factors were not associated with increased adjusted odds of pCVD. Overall, Black women had disproportionately higher rates of prepregnancy hypertension compared with White women (22% vs. 6%, p < 0.01). Conclusions: Women Veterans with pCVD are a high-risk group for future CVD, with disproportionately high rates of depression, anxiety, PTSD, and chronic stress. Racial disparities exist in pregnancy-related CV risk factors, which may further compound existing racial disparities in CVD among women Veterans. [ABSTRACT FROM AUTHOR]

Purpose: The optimum approach to providing the Congressionally mandated gender-specific services for which women veterans are eligible is unknown. We evaluated onsite availability of gynecologic services, clinic type and staffing arrangements, and the impact of having a gynecology clinic (GYN) and/or an obstetrician gynecologist (OBGYN) routinely available. Methods: We analyzed data from the 2001 national VHA Survey of Women Veterans Health Programs and Practices (n = 136 sites; response rate, 83%). We assessed availability of gynecologic services, and evaluated differences in availability by clinic type (designated women''s health provider in primary care [PC], separate women''s health clinic for primary care [WHC], and/or separate GYN) and staffing arrangements (OBGYN routinely involved versus not). Main Findings: Out of 133 sites, 77 sites (58%) offered services through a GYN and 56 sites (42%) did not have GYN. Seventy-two (54%) sites had a WHC. More sites with an OBGYN provided endometrial biopsies (91% vs. 20%), IUD insertion (85% vs. 14%), infertility evaluation (56% vs. 23%), infertility treatment (25% vs. none), gynecologic surgery (65 vs. 28%), p < .01. In comparison to sites without WHC, those with WHC were more likely to offer services onsite: endometrial biopsy odds ratio (OR) 6.0 (95% confidence interval [CI], 2.0–18.1); IUD insertion 4.4 (1.6–12.2); infertility evaluation 2.8 (1.2–6.3); and gynecologic surgery 2.3 (1.0–5.4). Conclusion: As the VA develops strategic plans for accommodating the growing number of women veterans, leaders should consider focusing on establishing WHC for primary care and routine availability of OBGYN or other qualified clinicians, rather than establishing separate GYN. [Copyright &y& Elsevier]

Objectives. We sought to examine whether physician recommendations for cardiac revascularization vary according to patient race. Methods. We studied patients scheduled for coronary angiography at 2 hospitals, one public and one private, between November 1997 and June 1999. Cardiologists were interviewed regarding their recommendations for cardiac resvacularization. Results. African American patients were less likely than Whites to be recommended for revascularization at the public hospital (adjusted odds ratio [OR] = 0.31; 95% confidence interval [CI] = 0.12, 0.77) but not at the private hospital (adjusted OR = 1.69; 95% CI = 0.69, 4.14). Conclusions. Physician recommendations for cardiac revascularization vary by patient race. Further studies are needed to examine physician bias as a factor in racial disparities in cardiac care and outcomes. (Am J Public Health. 2003;93:1689-1693) [ABSTRACT FROM AUTHOR]

Introduction: Presence of a firearm is associated with increased risk of violence and suicide. United States military veterans are at disproportionate risk of suicide. Routine healthcare provider screening of firearm access may prompt counseling on safe storage and handling of firearms. The objective of this study was to determine the frequency with which Veterans Health Administration (VHA) healthcare providers document firearm access in electronic health record (EHR) clinical notes, and whether this varied by patient characteristics. Methods: The study sample is a post-9-11 cohort of veterans in their first year of VHA care, with at least one outpatient care visit between 2012-2017 (N = 762,953). Demographic data, veteran military service characteristics, and clinical comorbidities were obtained from VHA EHR. We extracted clinical notes for outpatient visits to primary, urgent, or emergency clinics (total 105,316,004). Natural language processing and machine learning (ML) approaches were used to identify documentation of firearm access. A taxonomy of firearm terms was identified and manually annotated with text anchored by these terms, and then trained the ML algorithm. The random-forest algorithm achieved 81.9% accuracy in identifying documentation of firearm access. Results: The proportion of patients with EHR-documented access to one or more firearms during their first year of care in the VHA was relatively low and varied by patient characteristics. Men had significantly higher documentation of firearms than women (9.8% vs 7.1%; P < .001) and veterans >50 years old had the lowest (6.5%). Among veterans with any firearm term present, only 24.4% were classified as positive for access to a firearm (24.7% of men and 20.9% of women). Conclusion: Natural language processing can identify documentation of access to firearms in clinical notes with acceptable accuracy, but there is a need for investigation into facilitators and barriers for providers and veterans to improve a systemwide process of firearm access screening. Screening, regardless of race/ ethnicity, gender, and age, provides additional opportunities to protect veterans from self-harm and violence. [ABSTRACT FROM AUTHOR]

Prediabetes affects one-third of U.S. adults. Lifestyle change interventions, such as the Diabetes Prevention Program (DPP), can significantly lower type 2 diabetes risk, but little is known about how the DPP could be best adapted for women. This mixed-methods study assessed the impact of gender-tailoring and modality choice on DPP engagement among women Veterans with prediabetes. Participants were offered women-only groups and either in-person/peer-led or online modalities. Implementation outcomes were assessed using attendance logs, recruitment calls, and semi-structured interviews about patient preferences. Between June 2016 and March 2017, 119 women Veterans enrolled in the DPP (n = 51 in-person, n = 68 online). We conducted 22 interviews between August and September 2016 (n = 10 early-implementation) and March and July 2017 (n = 12 follow-up). Most interviewees preferred women-only groups, citing increased comfort, camaraderie, and mutual understanding of gender-specific barriers to lifestyle change. More women preferred online DPP, and those using this modality participated at higher rates. Most endorsed the importance of modality choice and were satisfied with their selection; however, selection was frequently based on participants' personal circumstances and access barriers and not on a "preferred choice" of two equally accessible options. Patient engagement and program reach can be expanded by tailoring the DPP for population-specific needs. [ABSTRACT FROM AUTHOR]

In the past decade, the U.S. Department of Veterans Affairs (VA) has responded to a dramatic increase in women veterans seeking care by expanding Women's Health training to more than 5,000 women's health primary care providers and changing the culture of the VA to be more inclusive of women veterans. These initiatives have resulted in increased patient satisfaction and quality of care, but have focused mostly on primary care settings. Less is known about women's experiences in specialty care within VA. This qualitative study sought to examine women veterans' experiences with VA specialty care providers, with a focus on cardiovascular, musculoskeletal, and mental health care settings. Semistructured interviews were conducted with 80 women veterans who served during the Iraq and Afghanistan conflicts at four VA facilities nationwide. Interviews focused on understanding women veterans' experiences with VA specialty care providers, including their perceptions of gender bias. Four major themes emerged from interviews, including that 1) women did not feel that VA specialty care providers listened to them or took their symptoms seriously, 2) women were told their health conditions or symptoms were attributable to hormonal fluctuations, 3) women noted differences in care based on whether the VA specialty provider was male or female, and 4) women provided recommendations for how gender-sensitive specialty care might be improved. This study is the first to highlight the perceived gender bias experienced by women veterans in VA specialty care. Women felt that their symptoms were disregarded or diminished by their specialty care providers. Although women veterans report positive experiences within women's health clinics and the primary care setting, their negative experiences in VA specialty care suggest that some providers may harbor unintentional or unconscious gender biases. [ABSTRACT FROM AUTHOR]

Pulmonary function testing (PFT) is required to diagnose chronic obstructive pulmonary disease (COPD) but is completed for only 30-50% of patients with the disease. We determined patient factors associated with decreased likelihood for PFT acquisition (i.e. underutilization) in the United States Veterans Affairs (VA) health care system. We performed a retrospective analysis of Veterans who survived a VA-based COPD hospitalization between 2012 and 2015. COPD was identified using International Classification of Disease (ICD)-9 codes. Our primary outcome was PFT acquisition, using Current Procedural Terminology (CPT) codes any time prior to the index hospitalization. We compared patients with and without PFTs and used logistic regression to identify associations with PFT underutilization. Of the 48,888 Veterans included, 78% underwent PFTs prior to hospitalization. Patients without PFTs were younger and more likely to be: women (4.2% vs. 3.6%; p = 0.01), nonwhite (22% vs. 19%; p < 0.0001), and current smokers (66% vs 61%; p < 0.0001). PFT acquisition was less likely in Veterans with alcohol and drug use disorders. Using logistic regression, Veterans who were women (Odds Ratio (OR) = 1.17 [95% confidence limit 1.03–1.32]), nonwhite (OR 1.12 [1.06–1.20]), and with a history of alcohol (OR = 1.07 [1.00–1.14]) or drug use disorders (OR = 1.15 [1.06–1.24]) were less likely to undergo PFTs. Though most Veterans hospitalized for COPD had PFTs prior to admission, PFTs are underutilized in Veterans who are: women, younger, nonwhite, and have alcohol or drug use disorders. These groups may be "at-risk" for delayed diagnosis or substandard COPD quality care. [ABSTRACT FROM AUTHOR]

The article presents a study which aims to explore the relationship between food insufficiency, an inadequate amount of food intake due to lack of money or resources and patient activation. It mentions that Chi-squared test and t test were used to examine the un-adjusted relationships between food sufficiency status and covariates. It states that programs that involve screening for food insecurity have been piloted in U.S. Department of Veterans Affairs Homeless clinics.

Background: In the U.S. civilian population, sex differences have been identified in cardiovascular health; these differences have been used to inform care. Our objective is to determine if the same sex differences are present in Veterans who use the Department of Veterans Affairs (VA) Health Care System given the additional stressors associated with military service. Materials and Methods: Cardiovascular disease (CVD) risk factors and conditions among women and men Veterans using VA in fiscal year (FY) 2014 were identified through the presence of International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes in VA administrative records. ICD-9-CM codes were grouped into conditions; prevalence was examined by gender overall, by age, and by race/ethnicity. Results: Within the FY 2014 cohort of VA Veteran patients included in this analysis, 7.1% (n = 412,901) were women and 92.9% were men (n = 5,376,749). Compared with men, women in this cohort were younger and more ethnically diverse. Overall, women were less likely to have traditional CVD risk factors, but more likely to have a nontraditional CVD risk factor (depression) compared with men. Women had higher odds of chest pain/angina (adjusted odds ratio [AOR] 1.03, confidence interval [95% CI] 1.02–1.05), palpitations (AOR 2.04; 95% CI 1.98–2.10), and valvular disease (AOR 1.05; 95% CI 1.02–1.08), but lower odds of coronary artery disease (AOR 0.29; 95% CI 0.29–0.30), acute MI (AOR 0.46; 95% CI 0.43–0.49), and heart failure (AOR 0.55; 95% CI 0.53–0.56) compared with men, overall. Conclusions: In age-adjusted comparisons, sex differences in the prevalence of CVD risk factors and conditions among the VA Veteran patient population was similar in that seen in the civilian population with a few exceptions. [ABSTRACT FROM AUTHOR]

One in four women Veterans who use the Veterans Health Administration (VA) screen positive for military sexual trauma and may need trauma-sensitive care and coordination. VA primary care providers (PCPs), women veterans' main source of care, need to be well-versed in trauma-sensitive approaches to care. Women veterans' numerical minority in the VA can make provider exposure to female patients inconsistent, which may impede PCP experience in providing appropriate care. To inform strategies for improving trauma-sensitive primary care, we sought to better understand PCPs' current approaches to providing care to women veterans with sexual trauma histories. We conducted semistructured telephone interviews with PCPs (n = 28) practicing in VA primary care clinics. Participants were asked about their experiences delivering trauma-sensitive care as well as best practices. Interviews were recorded, transcribed, and analyzed for major themes regarding barriers to and facilitators of trauma-sensitive care. Participants expressed challenges delivering care to women with sexual trauma histories, including 1) insufficient time, 2) lack of perceived proficiency and/or personal comfort (with general physical examinations as well as gender-specific care such as Pap, breast, and pelvic examinations), and 3) difficulties with fostering positive patient–provider relationships. Access to mental health resources was noted as a key facilitator of providing trauma-sensitive care. Participants also shared existing (and potential) best practices and recommendations, such as paying special attention to patient behavioral cues related to comfort. PCPs delivering care to women in VA facilities may benefit from an increased awareness of best practices to facilitate the delivery of trauma-sensitive care. [ABSTRACT FROM AUTHOR]

Abstract Background Identifying factors influencing patient experience and communication with their providers is crucial for tailoring comprehensive primary care for women veterans within the Veterans Health Administration. In particular, the impact of mental health (MH) conditions that are highly prevalent among women veterans is unknown. Methods From January to March 2015, we conducted a cross-sectional survey of women veterans with three or more primary care and/or women's health visits in the prior year at 12 Veterans Health Administration sites. Patient measures included ratings of provider communication, trust in provider, and care quality; demographics, health status, health care use; and brief screeners for symptoms of depression, anxiety, and posttraumatic stress disorder. We used multivariate models to analyze associations of patient ratings and characteristics. Results Among the 1,395 participants, overall communication ratings were high, but significant variations were observed among women screening positive for MH conditions. In multivariate models, high communication ratings were less likely among women screening positive for multiple MH conditions compared with patients screening negative (odds ratio, 0.43; p <.001). High trust in their provider and high care ratings were significantly less likely among women with positive MH screens. Controlling for communication, the effect of MH on trust and care ratings became less significant, whereas the effect of communication remained highly significant. Conclusions Women veterans screening positive for MH conditions were less likely to give high ratings for provider communication, trust, and care quality. Given the high prevalence of MH comorbidity among women veterans, it is important to raise provider awareness about these differences, and to enhance communication with patients with MH symptoms in primary care. [ABSTRACT FROM AUTHOR]

Background: The Enhancing Mental and Physical health of Women through Engagement and Retention or EMPOWER program represents a partnership with the US Department of Veterans Health Administration (VA) Health Service Research and Development investigators and the VA Office of Women's Health, National Center for Disease Prevention and Health Promotion, Primary Care-Mental Health Integration Program Office, Women's Mental Health Services, and the Office of Patient Centered Care and Cultural Transformation. EMPOWER includes three projects designed to improve women Veterans' engagement and retention in evidence-based care for high-priority health conditions, i.e., prediabetes, cardiovascular, and mental health.Methods/design: The three proposed projects will be conducted in VA primary care clinics that serve women Veterans including general primary care and women's health clinics. The first project is a 1-year quality improvement project targeting diabetes prevention. Two multi-site research implementation studies will focus on cardiovascular risk prevention and collaborative care to address women Veterans' mental health treatment needs respectively. All projects will use the evidence-based Replicating Effective Programs (REP) implementation strategy, enhanced with multi-stakeholder engagement and complexity theory. Mixed methods implementation evaluations will focus on investigating primary implementation outcomes of adoption, acceptability, feasibility, and reach. Program-wide organizational-, provider-, and patient-level measures and tools will be utilized to enhance synergy, productivity, and impact. Both implementation research studies will use a non-randomized stepped wedge design.Discussion: EMPOWER represents a coherent program of women's health implementation research and quality improvement that utilizes cross-project implementation strategies and evaluation methodology. The EMPOWER Quality Enhancement Research Initiative (QUERI) will constitute a major milestone for realizing women Veterans' engagement and empowerment in the VA system. EMPOWER QUERI will be conducted in close partnership with key VA operations partners, such as the VA Office of Women's Health, to disseminate and spread the programs nationally.Trial Registration: The two implementation research studies described in this protocol have been registered as required: Facilitating Cardiovascular Risk Screening and Risk Reduction in Women Veterans: Trial registration NCT02991534 , registered 9 December 2016. Implementation of Tailored Collaborative Care for Women Veterans: Trial registration NCT02950961 , registered 21 October 2016. [ABSTRACT FROM AUTHOR]

Background: Advancements in percutaneous coronary intervention (PCI) for treating obstructive coronary artery disease have reduced major adverse events, including mortality. Yet, evidence as to whether women and men experience similar outcomes is mixed. The objective was to examine sex differences in 1-year major adverse cardiac outcomes for the national population of patients undergoing PCI at Veterans Health Administration (VA) cardiac catheterization laboratories. Methods: All Veterans undergoing PCI at VA hospitals between October 1, 2007 and September 30, 2013 ( N = 64,757; Women = 1,040) were included. Cox proportional hazards models compared 1-year postprocedural outcomes [rehospitalization for myocardial infarction (MI), all-cause mortality, and major adverse cardiovascular events (MACE)] by sex. Results: Women Veterans undergoing PCI were more likely to be younger, black, obese, and have chronic depression and less likely to have common cardiovascular risk factors and to have had prior cardiac events than Veteran men. One-year rates for women versus men were 2.1% and 2.5% for rehospitalization ( p-value = 0.57); 3.5% and 4.9% for mortality ( p-value = 0.14), and 5.4% and 6.9% for MACE ( p-value = 0.18). There were no significant sex differences in any of the outcomes in Cox proportional hazards models. Conclusions: Despite differences in clinical risk factors at the time of PCI, women and men Veterans treated at VA cardiac catheterization laboratories experienced comparable 1-year rehospitalization for MI, mortality, and MACE post-PCI. These results demonstrated similar 1-year post-PCI outcomes for men and women in a national population of patients who have more comorbidities and mental health issues than the general population. [ABSTRACT FROM AUTHOR]

We postulated that associations between two specific provider characteristics, class (nurse practitioner relative to physician) and primary care providers who are proficient and interested in women's health (designated women's provider relative to nondesignated) and overall satisfaction with provider, were mediated through women veterans' perception of enough time spent with the provider. A national patient experience survey was administered to 7,620 women veterans. Multivariable models of overall patient satisfaction with provider were compared with and without the proposed mediator. A structural equation model (SEM) of the mediation of the two provider characteristics was also evaluated. Without the mediator, associations of provider class and designation with overall patient satisfaction were significant. With the proposed mediator, these associations became nonsignificant. An SEM showed that the majority (>80%) of the positive associations between provider class and designation and the outcome were exerted through patient perception of enough time spent with provider. Higher ratings of overall satisfaction with provider exhibited by nurse practitioners and designated women's health providers were exerted through patient perception of enough time spent with provider. Future research should examine what elements of provider training can be developed to improve provider-patient communication and patient satisfaction with their health care. [ABSTRACT FROM AUTHOR]

The article reports on a study which identify factors associated with women Veterans' receptivity to recommendation for alcohol related care when they present to Veterans Affairs (VA) primary care with alcohol misuse. It states that qualitative analyses identified several themes associated with women's receptivity which included self-appraisal of drinking behavior as severe, the provider's presentation of treatment options and availability of gender-specific services.

Background Women are a rapidly growing segment of patients who seek care in the Veterans Affairs (VA) Healthcare System, yet many questions regarding their health care experiences and outcomes remain unanswered. Racial and ethnic disparities have been well-documented in the general population and among veterans; however, prior disparities research conducted in the VA focused primarily on male veterans. We sought to characterize the findings and gaps in the literature on racial and ethnic disparities among women using the VA. Methods We systematically reviewed the literature on racial and ethnic health care disparities exclusively among women using the VA Healthcare System. We included studies that examined health care use, satisfaction, and/or quality, and stratified data by race or ethnicity. Results Nine studies of the 2,591 searched met our inclusion criteria. The included studies examined contraception provision/access (n = 3), treatment of low bone mass (n = 1), hormone therapy (n = 1), use of mental health or substance abuse–related services (n = 2), trauma exposure and use of various services (n = 1), and satisfaction with primary care (n = 1). Five of nine studies showed evidence of a significant racial or ethnic difference. Conclusion In contrast with the wealth of literature examining disparities both among the male veterans and women in non-VA settings, only nine studies examine racial and ethnic disparities specifically among women in the VA Healthcare System. These results demonstrate that there is an unmet need to further assess health care disparities among female VA users. [ABSTRACT FROM AUTHOR]

Background Little is known about the clinical profile and treatment priorities of women with binge eating disorder (BED), a diagnosis new to the fifth edition of Diagnostic and Statistical Manual of Mental Disorders . We identified comorbidities and patients' treatment priorities, because these may inform implementation of clinical services. Methods Data were collected from women veteran primary care patients. Analyses compared those who screened positive for BED (BED+), and those without any binge eating symptoms (BED−). Results Frequencies of comorbid medical and psychological disorders were high in the BED+ group. The BED+ group's self-identified most common treatment priorities were mood concerns (72.2%), weight loss (66.7%), and body image/food issues (50%). Among those with obesity, a greater proportion of the BED+ group indicated body image/food issues was their top treatment priority (12.9% vs. 2.8%; p < .01), suggesting that these patients may be more apt to seek treatment beyond weight management for their problematic eating patterns. Conclusions Women primary care patients with BED demonstrate high medical and psychological complexity; their subjective treatment priorities often match objective needs. These findings may inform the development of targeted BED screening practices for women with obesity in primary care settings, and the eventual adoption of patient-centered BED treatment resources. [ABSTRACT FROM AUTHOR]

Introduction: Although providing culturally sensitive health care is vitally important, there is little consensus regarding the most effective strategy for implementing cultural competence trainings in the health care setting. Evidence-based quality improvement (EBQI), which involves adapting evidencebased practices to meet local needs, may improve uptake and effectiveness of a variety of health care innovations. Yet, to our knowledge, EBQI has not yet been applied to cultural competence training. To evaluate whether EBQI could enhance the impact of an evidence-based training intended to improve veterans affairs health care staff gender sensitivity and knowledge (Caring for Women Veterans; CWV), we compared the reach and effectiveness of EBQI delivery versus standard web-based implementation strategies of CWV and assessed barriers and facilitators to EBQI implementation. Methods: Workgroups at four diverse veterans affairs health care sites were randomized to either an EBQI or standard web-based implementation condition (SI). All EBQI sites selected a group-based implementation strategy. Employees (N = 84) completed pretraining and posttraining assessments of gender sensitivity and knowledge, and focus groups/interviews were conducted with leadership and staff before and after implementation. Results: Reach of CWV was greater in the EBQI condition versus the SI condition. Whereas both gender sensitivity and knowledge improved in the EBQI condition, only gender sensitivity improved in the SI condition. Qualitative analyses revealed that the EBQI approach was well received, although a number of barriers were identified. Discussion: Findings suggest that EBQI can enhance the uptake and effectiveness of employee trainings. However, the decision to pursue EBQI must be informed by a consideration of available resources. [ABSTRACT FROM AUTHOR]

Background One in five women veterans screens positive for alcohol misuse. Women may be less likely than men to disclose alcohol use to a primary care provider (PCP), resulting in women being less likely to receive effective interventions. We sought to qualitatively examine factors that may affect women veterans' willingness to disclose alcohol use to a PCP. Methods Between October 2012 and May 2013, in-depth interviews were conducted with 30 women veterans at two Department of Veterans Affairs (VA) medical facilities. Qualitative data analyses identified common themes representing factors that influence women's decision to disclose alcohol use to a PCP. Findings Nine themes were endorsed by women veterans as influencing their willingness to disclose alcohol use to their PCP. Themes included provider behaviors perceived as encouraging or discouraging disclosure of alcohol misuse, perceived positive relationship with provider, negative emotions such as concerns about being judged or labeled an “alcoholic,” health concerns about drinking, non–health-related concerns about drinking, self-appraisal of drinking behavior, social support, and clinic factors. Conclusions Our findings demonstrate the importance of social relationships, comfort with one's provider, and education on the potential harms (especially health related) associated with alcohol in encouraging disclosure of alcohol use in women veterans. Our results also support VA national health care efforts, including the provision of brief alcohol counseling and the use of primary care clinics specializing in the care of women veterans. [ABSTRACT FROM AUTHOR]

Introduction: Vasomotor symptoms (VMS), including hot flashes and night sweats, are common among postmenopausal women and are associated with reduced health related quality of life (HRQOL). Purpose of the Study: To determine whether Veterans are more likely to report VMS than non-Veterans, and whether the association of VMS with HRQOL varies by Veteran status. Design and Methods: We used data from the Women's Health Initiative Observational Study, including self-reported baseline VMS presence and severity, and HRQOL at follow-up Year 3 (RAND Short Form 36-Item Health Survey). Employing generalized linear models we estimated whether Veteran status was associated with any VMS. We estimated the association between any VMS and HRQOL using linear regression, stratified by Veteran status. Interaction terms were added separately to determine whether the association varied by baseline depression, obesity, or smoking status. Results: The final analyses included 77,153 postmenopausal women (2,004 Veterans). After adjustment, Veterans were no more likely than non-Veterans to report any VMS at baseline (relative risk [RR] 0.97, 95% confidence interval [CI] 0.90-1.04) or moderate to severe VMS (RR 1.03, 95% CI 0.89-1.18). Any VMS was associated with decreased HRQOL at Year 3, particularly among Veterans (mean difference range: Veterans -2.7 to -4.6, p-values < .001; non-Veterans -2.2 to -2.6, 95% CI -0.13 to -0.09, p values < .001). Baseline depression and obesity, but not smoking, amplified the negative association between VMS and HRQOL. Implications: Multicondition care models for postmenopausal Veteran and non-Veteran women are needed that incorporate management strategies for VMS, weight, and depression [ABSTRACT FROM AUTHOR]

ABSTRACT: The majority of women Veterans using VA (Veterans Administration) care fall in the 45-65 year-old age range. Understanding how menopause is managed in this group is of importance to optimizing their health. OBJECTIVE: National population estimates showed a prevalence of hormone therapy (HT) use by women over 45 years of 4.7 % (2009-2010). Our study described the frequency of HT use among women Veterans in VA, and examined whether mental health (MH) was predictive of HT use. DESIGN: This was a cross-sectional analysis of national VA administrative data for fiscal year 2009. PARTICIPANTS: Women Veterans over the age of 45 ( N = 157,195) accessing VA outpatient care were included in the analysis. MAIN MEASURES: Logistic regression analyses using HT use as the dependent variable. KEY RESULTS: Mean age was 59.4 years (SD =12.2, range =46-110), and 16,227 (10.3 %) of all women used HT. Hysterectomy (OR 3.99 [3.53, 4.49]) and osteoporosis (1.34 [1.27, 1.42]) were the strongest medical indicators of HT use. A total of 49,557 (31.5 %) women in the sample received at least one primary diagnosis of a MH disorder and were more likely to use HT than women with no MH diagnoses (unadjusted OR 1.56, 95 % CI [1.50, 1.61]). Women Veterans with a mood disorder (depression/bipolar) or anxiety disorder [post-traumatic stress disorder (PTSD), other anxiety diagnoses] were more likely to use HT after controlling for demographics and medical comorbidity. CONCLUSION: The prevalence of HT use among women Veterans using VA is more than twice that of the general population. Prior work suggested that women Veterans were discontinuing HT at comparable rates, but these data demonstrate that decline in VA HT use has not kept pace with that of civilian medical care. The association of MH diagnosis with HT use suggests that MH plays an important role in VA rates. Further study is needed to understand contributing patient and provider factors. [ABSTRACT FROM AUTHOR]

Background Women veterans comprise a small percentage of Department of Veterans Affairs (VA) health care users. Prior research on women veterans' experiences with primary care has focused on VA site differences and not individual provider characteristics. In 2010, the VA established policy requiring the provision of comprehensive women's health care by designated women's health providers (DWHPs). Little is known about the quality of health care delivered by DWHPs and women veterans' experience with care from these providers. Methods Secondary data were obtained from the VA Survey of Healthcare Experience of Patients (SHEP) using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient-centered medical home (PCMH) survey from March 2012 through February 2013, a survey designed to measure patient experience with care and the DWHPs Assessment of Workforce Capacity that discerns between DWHPs versus non-DWHPs. Findings Of the 28,994 surveys mailed to women veterans, 24,789 were seen by primary care providers and 8,151 women responded to the survey (response rate, 32%). A total of 3,147 providers were evaluated by the SHEP-CAHPS-PCMH survey (40%; n = 1,267 were DWHPs). In a multivariable model, patients seen by DWHPs (relative risk, 1.02; 95% CI, 1.01–1.04) reported higher overall experiences with care compared with patients seen by non-DWHPs. Conclusions The main finding is that women veterans' overall experiences with outpatient health care are slightly better for those receiving care from DWHPs compared with those receiving care from non-DWHPs. Our findings have important policy implications for how to continue to improve women veterans' experiences. Our work provides support to increase access to DWHPs at VA primary care clinics. [ABSTRACT FROM AUTHOR]

INTRODUCTION: 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. OBJECTIVE: 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. METHODS: 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). RESULTS: 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). CONCLUSION: 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. [ABSTRACT FROM AUTHOR]