Development of Quality Indicators for the Care of Women with Abnormal Uterine Bleeding by Primary Care Providers in the Veterans Health Administration

An Evidence Map of the Women Veterans' Health Literature, 2016 to 2023: A Systematic Review

Importance

Women veterans are the fastest-growing veteran subpopulation in the US. Women veterans often experience military service-related health issues in addition to conditions common to all women. Because women veterans are more likely to receive care in the civilian setting than through the Department of Veterans Affairs (VA), all women's health clinicians should be equipped to provide patient-centered care for women veterans. The health care of women veterans requires evidence-based care informed by population-specific scientific literature. An updated evidence map evaluating women veteran-focused health literature is needed.

Objective

To map the scope and breadth of women veterans' health literature published from 2016 to 2023.

Evidence Review

In this systematic review, MEDLINE, Embase, and CINAHL Complete were searched for eligible articles published from 2016 to 2023. Articles reporting about US women veterans' health outcomes or on the experience of providing care to women veterans were included. Included articles were required to report patient-level outcomes that included either data for only women veterans or reported results separately for women veterans. Articles were grouped by primary focus area based on categories previously established by the VA Women's Health research agendas and prior evidence maps.

Findings

The volume of women veterans' health literature published between 2016 and 2023 of 932 articles was double that of the prior 8 years. The largest portion of this literature was focused on chronic medical conditions (137 articles [15%]), general mental health (203 articles [22%]), and interpersonal violence (121 articles 3[13%]). Areas of greatest growth included reproductive health (physical and mental), pain, suicide, and nonsuicidal self-injury. Additionally, emerging areas of inquiry were found, including military-related toxic exposures and harassment within the health care setting.

Conclusions and Relevance

In this systematic review of literature focused on the health of women veterans, the volume of literature was found to have doubled and expanded in important areas that aligned with VA research priorities. However, despite the growth in research related to women veterans, several important research gaps remain within this field of study. Research addressing health issues pertinent to a growing and aging women veterans' population will require rigorous research and program evaluations.

Guideline Adherence of Veterans Health Administration Primary Care for Abnormal Uterine Bleeding

BACKGROUND

Abnormal uterine bleeding (AUB) is common among primary care patients. We assessed the extent to which Veterans Health Administration (VA) primary care patients with AUB are receiving guideline-adherent primary care.

METHODS

We identified women with AUB presenting to primary care providers across four VA health care systems from June 2013 to September 2015. We performed a structured abstraction of electronic medical record data for 15 indicators of guideline-adherent AUB care. We determined whether documented care was guideline-adherent and compared adherence of care by primary care providers by VA Designated Women's Health Provider status and by volume of clinical encounters with women veterans.

RESULTS

Across 305 episodes of AUB, 53% of the care was guideline adherent. There was high adherence with documenting menopausal status (98%), ordering diagnostic studies and referrals for postmenopausal women (92%), and documenting bleeding patterns (87%). There was lower adherence with documenting whether there was active bleeding (55%), performing thyroid testing (47%), performing a pelvic examination (42%), ordering diagnostic studies and referrals in younger women with increased endometrial cancer risk (40%), assessing for pregnancy (32%), assessing for cervical motion, uterine, or adnexal tenderness in patients with intrauterine devices (30%), and assessing for elevated endometrial cancer risk (6%). There were no significant differences in overall guideline adherence between primary care providers who were, versus were not, VA Designated Women's Health Providers, or by provider volume of encounters with women veterans.

CONCLUSIONS

VA primary care has high guideline adherence when caring for postmenopausal women with AUB. Quality improvement and educational initiatives are needed to improve primary care for AUB in younger women veterans.