1. Assuring High Quality Primary Care for Women Veterans: Predictors of Success Bevanne Bean-Mayberry, MD, MHS Chung-Chou Chang, PhD Melissa McNeil, MD, MPH Sarah Hudson Scholle, DrPH VA Pittsburgh & University of Pittsburgh

2. Why Study Women in the VA? One of the fastest growing VA populations Numbers exceed 1.7 million nationally 15% of active military and reserve forces 20% of new recruits prior to current Persian Gulf War Gaps in care and vulnerable health risks resulted in Public Law 102- 585 to improve VA preventive and gender-specific care Health care issues for women in the VA are different from men and different from civilian women

3. Background: Womens Health In the US, health care for women is often fragmented, and primary care goals such as comprehensiveness and coordination are difficult to achieve In the VA, reports on women veteran health care have repeatedly documented problems with gender-sensitivity, comprehensiveness and coordination of care VA promoted specialized womens clinics or teams to address the issues, yet nearly a quarter of VA facilities lack formal approaches for addressing these primary care goals

4. Background: Womens Health Factors associated with attainment of primary care goals: Female Providers: »increased gynecological and mammography services »Increased gender-specific counseling and communication Gynecological Services: »33-50% of women use a gynecologist and generalist »women prefer gynecological care at the same site where they obtain general care Womens Health Settings: »comparable or better preventive care and satisfaction

5. Research Question What is the effect of combining female provider, routine gynecological care from the provider, and womens health setting on patient ratings of primary care?

6. Aim and Hypotheses Specific Aim: To determine if the combined effects of provider gender, routine gynecologic services from the provider, and womens clinic setting improve patient ratings of primary care quality Hypotheses: Women in general primary care settings will have higher primary care quality ratings 1. If the regular provider is female 2. If the regular provider manages routine gynecological care 3. If the patient participates in a gender-specific womens clinic setting

7. Methods Study Population: Stratified random sample of women veterans from clinics in 10 VAMCs in VISN 4 (Pennsylvania, West Virginia, and Delaware region) obtained from the VA National Patient Care Database Eligibility criteria: »Female veterans »>1 outpatient visit March 1,1999 to March 1, 2000 »Use of traditional primary care or womens clinic Design: Cross-sectional, anonymous survey (2000)

8. Methods: Measures Tool: Components of Primary Care Index (Flocke 1997) Dependent variables: 4 domains »1) Patient preference for provider (i.e., continuity) »2) Interpersonal communication »3) Coordination of care »4) Accumulated Knowledge Domain scoring: »6 point scale (i.e., strongly disagree to strongly agree) »Summary score adjusted for 1-2 missing items, no imputations »Responses dichotomized to perfect score vs. all other

9. Methods: Measures cont. Independent variables: »Gender of VA provider »Routine gynecological care managed by VA provider »Use of a VA womens clinic setting All three items were combined into 6 exclusive Provider - service – clinic categories Control variables: age, race, marital status, education, income, health status, and site

10. Provider-Service-Clinic Categories Female PCP + GYN + WC Female PCP + GYN Female PCP + WC Female PCP only Male PCP + GYN +/or WC Male PCP Note: PCP = Primary care provider; GYN = Gynecological care by provider; WC = Womens clinic

11. Analytic Sample

12. Analysis Patient characteristics were described and patients were grouped along 6 provider – service – clinic categories to look for differences Multiple logistic regression was used to identify factors independently associated with perfect ratings on each primary care domain

13. Results: Patient Characteristics AgePercentage <40 years14.8% 40-64 years44.4% 65+ years41.8% Race, white89.5% Education- High school30.5% Some college/ technical training45.7% College graduate23.8% Married33.6% Annual income > $20,00037.7% Health status (very good/excellent)31.6% Enrollment in womens clinic52.4%

14. Results: Provider-Service-Clinic Female PCP + GYN + WC29.1% Female PCP + GYN11.8% Female PCP + WC10.3% Female PCP only16.0% Male PCP + GYN +/or WC17.0% Male PCP16.0% Note: PCP = Primary care provider; GYN = Gynecological care by provider; WC = Womens clinic

15. Adjusted Odds of a Perfect Score: Patient Preference for Provider Adjusted OR (95%CI) Female PCP + GYN + WC 4.7 (2.3, 9.7) Female PCP + GYN4.0 (1.8, 8.7) Female PCP + WC1.8 (0.7, 4.1) Female PCP only2.2 (0.9, 4.5) Male PCP + GYN and/or WC2.1 (1.0, 4.4) Male PCP only (referent group)-

16. Adjusted Odds of a Perfect Score: Interpersonal Communication Adjusted OR (95%CI) Female PCP + GYN + WC 2.7 (1.4, 5.3) Female PCP + GYN2.7 (1.3, 5.5) Female PCP + WC1.8 (0.8, 4.0) Female PCP only2.9 (1.4, 5.8) Male PCP + GYN +/- WC1.3 (0.6, 2.6) Male PCP only (referent group)-

17. Adjusted Odds of a Perfect Score: Coordination of Care Adjusted OR (95%CI) Female PCP + GYN + WC 2.3 (1.0, 5.5) Female PCP + GYN2.8 (1.1, 7.1) Female PCP + WC2.7 (1.0, 7.1) Female PCP only3.7 (1.5, 9.0) Male PCP + GYN +/- WC3.0 (1.2, 7.0) Male PCP only (referent group)-

18. Adjusted Odds of a Nearly Perfect Score: Accumulated Knowledge Adjusted OR (95%CI) Female PCP + GYN + WC 6.1 (1.3, 28.5) Female PCP + GYN4.6 (0.9, 22.8) Female PCP + WC4.0 (0.7, 22.5) Female PCP only3.8 (0.8, 19.2) Male PCP + GYN +/- WC2.6 (0.5, 13.0) Male PCP only (referent group)-

19. Limitations Data are cross-sectional, retrospective and generalize only to the VA setting Non-respondents could not be identified No information on clustering of providers Provider – clinic – service categories were limited due to size of groups Findings are based only on patient ratings without additional evidenced-based indicators of quality

20. Summary of Perfect Ratings Communication: »strongest association with female PCP Coordination: »strongest association with female PCP Preference for provider: »strongest association with female PCP, GYN care, and WC Accumulated Knowledge: »strongest association with female PCP, GYN care, and WC

21. Conclusions Female providers who manage routine gynecological care (within or exclusive of womens clinic settings) have combined effects associated with high patient primary care ratings Male providers who manage routine gynecological care or may interact in womens clinic settings have effects associated with high patient primary care ratings

22. Implications for Women in VA Availability of provider choice and comprehensive services (inclusive of routine gynecological care) may result in less fragmentation and better primary care However…. Data are needed on the structural components of these organizational models for women in the VA, and…. Data are needed on the clinical outcomes for women in these different health care delivery models Without these data, health care policy will not reflect quality measures and VA practice structure

23. Funding Dr. Bean-Mayberrys support: VA HSR&D Career Development Award #02-039-2 VISN 4 Competitive Pilot Project Funds VA Office of Academic Affairs, Womens Health Fellowship University of Pittsburgh, School of Public Health Mentors: Dr. Sarah Hudson Scholle, NCQA & University of Pitt. Dr. Michael Fine, Director, CHERP, VA Pittsburgh Dr. Elizabeth Yano, Deputy Director, VA Greater Los Angeles HSR&D Center of Excellence

24. Questions

25. Public Health Law 102-585 The Women Veterans Health Programs Act covered: counseling for military related sexual trauma broadening clinical services to include reproductive and gender-specific care (excluding infertility/abortion) expansion of health care services available and accessible to women veterans; support for women veteran coordinators in each regional office of the VA (VA Health Care for Women, January 1999; HR 5193; Bill Summary and Status for the 102 nd Congress at http://thomas.loc.gov/cgi bin/bdquery/z?d102:HR05193.).http://thomas.loc.gov/cgi bin/bdquery/z?d102:HR05193.

26. Results: Proportion of Perfect Scores Primary Care Domains% Perfect Scores Patient preference for provider23.1% Interpersonal communication25.8% Coordination of care16.4% Accumulated knowledge* 6.8% *Accumulated Knowledge was based on nearly perfect scores.