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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., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

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., (© 2022. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

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., (© 2022. The Author(s).)

Unlabelled: 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.

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.

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.

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.

The Department of Veterans Affairs (VA) and other federal agencies require funded researchers to include women in their studies. Historically, many researchers have indicated they will include women in proportion to their VA representation or pointed to their numerical minority as justification for exclusion. However, women's participation in the military-currently 14% of active military-is rapidly changing veteran demographics, with women among the fastest growing segments of new VA users. These changes will require researchers to meet the challenge of finding ways to adequately represent women veterans for meaningful analysis. We describe women veterans' health and health-care use, note how VA care is organized to meet their needs, report gender differences in quality, highlight national plans for women veterans' quality improvement, and discuss VA women's health research. We then discuss challenges and potential solutions for increasing representation of women veterans in VA research, including steps for implementation research.

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.

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.