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) HypertensionDepressionHyperlipidemia 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 ConditionFemaleMalep-value “Heart condition” 9.6%16.4%<.0001 Stroke1.5%3.1%.01 Diabetes mellitus 6.4%11.5%<.0001 HIV / Hepatitis C 1.7%1.8%NS Substance use disorder 0.8%1.3%NS Mental Health 15.9%7.8%<.0001 Source: National Survey of Veterans 2001

6. % of Veteran VA users receiving treatment in prior year for selected QUERI conditions, by gender ConditionFemaleMalep-value “Heart condition” 17.7%28.9%.0023 Stroke2.6%6.2%.016 Diabetes mellitus 8.3%19.8%<.0001 HIV / Hepatitis C 5.2%4.8%NS Substance use disorder 2.0%2.9%NS Mental Health 32.9%19.5%<.0001 Source: National Survey of Veterans 2001

7. PTSD Prevalence and Treatment Women Veterans PTSD screening test positive* Mental health care use prior 12 months for PTSD +’s* All women veterans 10.9%27.3% VA users VA users26.0% 63.7% 63.7% VA-nonusers VA-nonusers 9.7% 9.7%19.9% *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+) WV Health Program Act (P.L. 102-585) Comprehensive Women’s Health Centers Funded Gulf War OEF OIF GAO Report Source: Yano, Washington et al. Women’s Health Issues. 2006. Legislated WH service expansion

10. What Does VA Women’s Primary Care Look Like Now? Source: Yano, Washington, Bean-Mayberry, HSR&D #IIR 04-036 (2007) BUT 44% deliver gender-specific exams only 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 Source: Yano, Washington & Bean-Mayberry, VHA Survey of Women’s Health Programs & Practices, 2007. 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

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

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 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 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 VAusers VA nonusers Women’s health care 27%24% Other primary care 28%50% Mental health care 13% 3% 3% Other specialty care 12%14% Prescription benefits 14% 6% 6% Other 2% 2% 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