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Women Veterans’ Health Care Needs and Use

Women Veterans’ Health Care Needs and Use. Donna L. Washington, MD, MPH Core Investigator and Staff Physician VA Greater Los Angeles Healthcare System December 2008. Overview of Women Veterans’ :. Physical and mental health burdens Organization of VA care to meet their needs

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Women Veterans’ Health Care Needs and Use

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  1. Women Veterans’ Health Care Needs and Use Donna L. Washington, MD, MPH Core Investigator and Staff Physician VA Greater Los Angeles Healthcare System December 2008

  2. Overview of Women Veterans’ : • Physical and mental health burdens • Organization of VA care to meet their needs • VA health care use

  3. Women veterans’ have substantial chronic disease burden… Top diagnoses: • Post-traumatic stress disorder (PTSD) • Hypertension • Depression • Hyperlipidemia • Chronic low back pain • Gynecologic problems Source: Frayne et al. VA Women’s Health Program Evaluation, 1999; VA National Patient Care Database, 2004.

  4. …and Substantial Physical / Mental Health Comorbidities • Mental illness very high among women veterans with chronic conditions • 31% of women veterans with diabetes screen positive for depression, anxiety disorder or PTSD • 37% of women veterans with cardiovascular disorders (heart disease, CHF, stroke) have diagnosed depression Source: Washington & Yano, VA HSR&D #IAE 06-083, VISN22, 2004.

  5. % of Veterans (VA users & nonusers) receiving treatment in prior year for selected QUERI conditions Source: National Survey of Veterans 2001

  6. % of Veteran VA users receiving treatment in prior year for selected QUERI conditions, by gender Source: National Survey of Veterans 2001

  7. PTSD Prevalence and TreatmentWomen Veterans *p<0.0001 for VA-user versus VA-nonuser comparison Source: Washington & Yano, VA HSR&D #IAE 06-083, VISN22, 2004.

  8. VA Health Care for Women Veterans • Women veterans who use the VA have unique health care needs • Lower functional status vs. male vets, non-vet women • Special mental health care needs (PTSD, MST) • Congressional eligibility reforms changed array of services available to women veterans • Including mandated provision of gender-specific services • VHA faces considerable challenges in meeting those needs • Complicated casemix, growing caseload & services

  9. Expansion of VA Women’s Health Clinics & Women Veteran Caseload in VA Facilities (1985+) Legislated WH service expansion Comprehensive Women’s Health Centers Funded WV Health Program Act (P.L. 102-585) GAO Report OEF Gulf War OIF Source: Yano, Washington et al. Women’s Health Issues. 2006.

  10. What Does VA Women’s Primary Care Look Like Now? BUT 44% deliver gender-specific exams only Source: Yano, Washington, Bean-Mayberry, HSR&D #IIR 04-036 (2007) GYN clinic 9% no GYN clinic 11%

  11. So What is the Problem? • Primary care is fragmented for women veterans • What would be routine primary care in community settings is referred out to specialty women’s health in VA • 54% refer Pap smears • 47% refer clinical breast exams • 47% refer contraceptive counseling • 46% refer vaginitis evaluation • 46% refer menopausal management • 16% refer osteoporosis management • 15% refer sexual trauma screening Source: Yano, Washington, Bean-Mayberry (HSR&D #IIR 04-036) (2007)

  12. Integrated Primary Care • 42% of VAs have designated WH providers in general PC to whom women veterans are preferentially assigned • 56% have one for whole PC practice • 9% have one in each PC team • 18% have a WH primary care team • Others: randomly assigned, count NPs, no specifics • Lack adequate clinical expertise in WH (p<.05) • Lack same-gender providers (p<.01) • Designated WH providers only available 6 half-day sessions/week Source: Yano, Washington, Bean-Mayberry (VA HSR&D #IIR 04-036) (2007)

  13. Barriers to delivering high quality health care to Women Veterans Space limitations or ability to assure privacy Small women veteran caseload Inability to recruit specialists Insufficient # clinicians skilled in women’s health Competing local or network priorities Highly competitive health care market for women Source: Yano, Washington & Bean-Mayberry, VHA Survey of Women’s Health Programs & Practices, 2007.

  14. Women Veterans Use VA Differently • Women veterans underutilize VA health care compared to male veterans • Among VA users, women more likely to concurrently use VA and non-VA healthcare Source: FY2006 VA NPCD and 2000 US Census

  15. Women Veterans Use VA Differently • Women have 11.8% more outpatient visits, 25.9% fewer inpatient days and 11.4% lower costs compared to men • After adjusting for age and medical comorbidity, differences less pronounced (1.3%, 10.9%, and 2.8%) • Among 30.8% of women and 24.4% of men with medical and mental health conditions, women use care more heavily (31.0 vs. 27.3 visits) • Women 3x more likely to use fee basis care Source: Frayne et al, J Women’s Health, 2007 Oct; 16:1188-99.

  16. VA users VA nonusers Lack of information about VA and perceptions of poor VA quality are barriers to VA use for Women Veterans Knowledge gap for VA benefits Misperceptions of availability of VA women’s health services VA quality of care rated high Perception that VA physicians not skilled in treating women Washington DL, et.al. J Gen Intern Med. 2006 Mar; 21:S11-18.

  17. Women veterans prefer . . . • One-stop shopping • Receiving general & women’s health care from the same provider or clinic rated very important for 55% of VA users • Availability of Women’s health clinics • Rated very important for 44% of VA-users, 29% of VA-nonusers Washington DL, et.al. J Gen Intern Med. 2006 Mar; 21:S11-18.

  18. . . . but they often receive fragmented care • Different components of health care for women provided by different providers with varying degrees of coordination • Women veteran VA users: • 28% have one VA provider or clinic for both primary care and women’s health • 21% receive primary care and women’s health from different VA clinics • 51% concurrently use VA and non-VA for different components of care Source: Washington & Yano, VA HSR&D #IAE 06-083, VISN22, 2004.

  19. Main Healthcare Service Used Source: Washington & Yano, VA HSR&D #IAE 06-083, VISN22, 2004.

  20. Conclusions • Co-morbid physical and mental health conditions • Women’s health is cross-cutting issue for QUERI stakeholders • Fragmentation of women’s health care inherent in VA delivery arrangements and in women veterans’ dual use of VA/non-VA systems of care • Implications for coordination across sites of care and women veteran-focused interventions

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