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Callegari LS, Benson SK, Mahorter SS, Nelson KM, Arterburn DE, Hamilton AB, Taylor L, Hunter-Merrill R, Gawron LM, Dehlendorf C, Borrero S. Evaluating the MyPath web-based reproductive decision support tool in VA primary care: Protocol for a pragmatic cluster randomized trial. Contemp Clin Trials 2022; 122:106940. [PMID: 36179982 DOI: 10.1016/j.cct.2022.106940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Counseling to identify and support individuals' desires for family formation is a key component of preventive health care that is often absent in primary care visits. This study evaluates a novel, web-based, person-centered intervention to increase the frequency and quality of communication about reproductive goals and healthcare needs in Veterans Health Administration (VA) primary care. METHODS We describe a hybrid type 1 effectiveness-implementation cluster randomized controlled trial in seven VA healthcare systems testing a web-based reproductive health decision support tool (MyPath). VA primary care providers are enrolled and randomized to intervention or usual care arms. Veterans scheduled to see intervention-arm providers receive a text message inviting them to use MyPath ahead of their appointment; Veterans scheduled to see control-arm providers receive usual care. Target enrollment is 36 providers and 456 Veterans. Outcomes are assessed by Veteran self-report after the visit and at 3- and 6-months follow-up. The primary outcome is occurrence of reproductive health discussions involving shared decision making; secondary outcomes include measures of communication, knowledge, decision conflict, contraceptive utilization, and receipt of services related to prepregnancy health. Data on implementation barriers, facilitators and cost are collected. RESULTS The trial is ongoing with no results to report. We have enrolled 36 primary care providers across 7 VA healthcare systems and recruitment of Veterans is ongoing. CONCLUSIONS Results will inform efforts to increase the quality and person-centeredness of reproductive healthcare delivery in primary care and to operationalize and scale up use of digital decision support tools in clinical settings. TRIAL REGISTRATION http://ClinicalTrials.gov Identifier: NCT04584294 Trial Status: Recruiting.
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Affiliation(s)
- Lisa S Callegari
- Health Services Research and Development, Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, USA; Department of Obstetrics & Gynecology, University of Washington School of Medicine, Seattle, USA; Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, USA.
| | - Samantha K Benson
- Health Services Research and Development, Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, USA
| | - Siobhan S Mahorter
- Health Services Research and Development, Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, USA
| | - Karin M Nelson
- Health Services Research and Development, Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, USA; Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, USA; Department of Medicine, University of Washington School of Medicine, Seattle, USA
| | - David E Arterburn
- Kaiser Permanente Washington Health Research Institute, Seattle, USA
| | - Alison B Hamilton
- Health Services Research and Development, VA Greater Los Angeles Healthcare System, Los Angeles, USA; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, USA
| | - Leslie Taylor
- Health Services Research and Development, Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, USA
| | - Rachel Hunter-Merrill
- Health Services Research and Development, Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, USA
| | - Lori M Gawron
- Health Services Research and Development, VA Salt Lake City Health Care System, Salt Lake City, USA; Department of Obstetrics & Gynecology, University of Utah School of Medicine, Salt Lake City, USA
| | - Christine Dehlendorf
- Department of Family and Community Medicine, University of California San Francisco School of Medicine, San Francisco, USA
| | - Sonya Borrero
- Center for Health Equity, Research, and Promotion, VA Pittsburgh Health Care System, Pittsburgh, USA; Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA
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Loho H, Rosenheck RA. Provision of Mental Health Services in the Veterans Health Administration: A Nationwide Comparison With Other Providers. Psychiatr Serv 2022; 74:472-479. [PMID: 36300285 DOI: 10.1176/appi.ps.202100713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Public interest in developing a national health care system has grown in the United States, but so have concerns that a large system would provide poor care. The Veterans Health Administration (VHA) is the largest national U.S. health care system, and several of its performance measures have been compared with those of non-VHA organizations. However, few studies have compared VHA's overall provision of mental health care services, and this study aimed to fill this gap. METHODS Using 2018 National Mental Health Services Survey data, the authors examined the differences in provision of 45 treatment modalities, specialized services, and dedicated programs between self-identified VHA facilities (N=459), non-VHA facilities that serve only adults (N=3,671), and non-VHA facilities that serve all ages (N=6,378). RESULTS Self-identified VHA facilities offered more services (including more treatment modalities, specialized services, and dedicated programs) (mean±SD=24.2±8.9 services) than both non-VHA adult-only facilities (15.4±6.8; Cohen's d=1.11, p<0.001) and non-VHA all-ages facilities (17.1±6.6; Cohen's d=0.90, p<0.001). Notably, VHA facilities were more likely to offer electroconvulsive therapy and telemedicine. VHA facilities were more likely to offer integrated primary care, chronic illness management, supportive housing, vocational rehabilitation, and psychiatric emergency services, among others. Last, VHA facilities were more likely to offer dedicated treatment programs for patients identifying as lesbian, gay, bisexual, or transgender, as well as for patients with posttraumatic stress disorder, traumatic brain injury, or dementia. CONCLUSIONS VHA facilities offer no fewer and possibly more comprehensive mental health services per facility than do non-VHA facilities, possibly because VHA represents an integrated and centralized health system.
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Affiliation(s)
- Hieronimus Loho
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (Loho, Rosenheck); New England Mental Illness Research, Education and Clinical Center, U.S. Department of Veterans Affairs, West Haven, Connecticut (Rosenheck)
| | - Robert A Rosenheck
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (Loho, Rosenheck); New England Mental Illness Research, Education and Clinical Center, U.S. Department of Veterans Affairs, West Haven, Connecticut (Rosenheck)
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Callegari LS, Mahorter SS, Benson SK, Zhao X, Schwarz EB, Borrero S. Perceived Contraceptive Counseling Quality Among Veterans Using VA Primary Care: Data from the ECUUN Study. J Gen Intern Med 2022; 37:698-705. [PMID: 36042079 PMCID: PMC9481768 DOI: 10.1007/s11606-022-07586-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 04/01/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND High-quality contraceptive counseling is critical to support Veterans' reproductive autonomy and promote healthy outcomes. OBJECTIVE To describe perceived quality of contraceptive counseling in Veterans Health Administration (VA) primary care and assess factors associated with perceived high- and low-quality contraceptive counseling. DESIGN Cross-sectional study using data from the Examining Contraceptive Use and Unmet Need in women Veterans (ECUUN) national telephone survey. PARTICIPANTS Veterans aged 18-44 who received contraceptive services from a VA primary care clinic in the past year (N=506). MAIN MEASURES Perceived quality of contraceptive counseling was captured by assessing Veterans' agreement with 6 statements regarding provider counseling adapted from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. High-quality counseling was defined as a top score of strongly agreeing on all 6 items; low-quality counseling was defined as not agreeing (neutral, disagreeing, or strongly disagreeing) with >3 items. We constructed two multivariable models to assess associations between patient-, provider-, and system-level factors and perceived high-quality (Model 1) and perceived low-quality counseling (Model 2). KEY RESULTS Most participants strongly agreed that their providers listened carefully (74%), explained things clearly (77%), and spent enough time discussing things (71%). Lower proportions strongly agreed that their provider discussed more than one option (54%), discussed pros/cons of various methods (44%), or asked which choice they thought was best for them (62%). In Model 1, Veterans who received care in a Women's Health Clinic (WHC) had twice the odds of perceiving high-quality counseling (aOR=1.99; 95%CI=1.24-3.22). In Model 2, Veterans who received care in a WHC (aOR=0.49; 95%CI=0.25-0.97) or from clinicians who provide cervical cancer screening (aOR=0.49; 95%CI=0.26-0.95) had half the odds of perceiving low-quality counseling. CONCLUSIONS Opportunities exist to improve the quality of contraceptive counseling within VA primary care settings, including more consistent efforts to seek patients' perspectives with respect to contraceptive decisions.
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Affiliation(s)
- Lisa S Callegari
- Health Services Research and Development, Department of Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way S-152, Seattle, WA, 98108, USA. .,Department of Obstetrics & Gynecology, University of Washington School of Medicine, Seattle, USA. .,Department of Health Services, University of Washington School of Public Health, Seattle, USA.
| | - Siobhan S Mahorter
- Health Services Research and Development, Department of Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way S-152, Seattle, WA, 98108, USA
| | - Sam K Benson
- Health Services Research and Development, Department of Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way S-152, Seattle, WA, 98108, USA
| | - Xinhua Zhao
- Center for Health Equity, Research, and Promotion, VA Pittsburgh Health Care System, Pittsburgh, USA
| | | | - Sonya Borrero
- Center for Health Equity, Research, and Promotion, VA Pittsburgh Health Care System, Pittsburgh, USA.,Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA
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Cardiovascular Risk Screening among Women Veterans: Identifying Provider and Patient Barriers and Facilitators to Develop a Clinical Toolkit. Womens Health Issues 2022; 32:284-292. [PMID: 35115227 DOI: 10.1016/j.whi.2021.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 11/15/2021] [Accepted: 12/09/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Cardiovascular (CV) disease is the leading cause of death among women in the United States, making CV risk screening and management a women's health priority. Objectives were to elicit barriers and facilitators to CV risk identification and reduction among women veterans, and iteratively cocreate clinical tools to identify CV risk factors and promote goal-setting for lifestyle changes. METHODS We conducted three exploratory focus groups with 21 Veterans Health Administration primary care team members and piloted patient CV screeners with brief interviews with 19 patients from two Veterans Health Administration women's clinics to inform toolkit development. We then conducted two focus groups and one interview for feedback from a total of 12 staff on the proposed toolkit components. Transcripts were summarized, and a matrix analysis was used to synthesize qualitative findings. RESULTS Provider-identified barriers included difficulties disseminating CV information in clinic, limited patient knowledge, and lack of organized resources for provider communication and available referrals. Women's complex health needs were notable challenges to CV risk reduction. Facilitators included having a single place to track patient CV risks (e.g., an electronic template note), a patient screening worksheet, and aids to complete referrals. Patient-identified barriers included difficulties balancing health, finances, and physical and mental health concerns. Facilitators included resources for accountability and gender-specific information about CV risks and complications. Providers requested easy, accessible tools in the electronic record with gender-specific CV data and resources linked. Patients requested lifestyle change supports, including trustworthy sources vetted by providers. CONCLUSIONS Iteratively eliciting end-users' perspectives is critical to developing user-friendly, clinically relevant tools. CV risk reduction among women veterans will require multilevel tools and resources that meet providers' and women's needs.
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Callegari LS, Nelson KM, Arterburn DE, Dehlendorf C, Magnusson SL, Benson SK, Schwarz EB, Borrero S. Development and Pilot Testing of a Patient-Centered Web-Based Reproductive Decision Support Tool for Primary Care. J Gen Intern Med 2021; 36:2989-2999. [PMID: 33538956 PMCID: PMC8481447 DOI: 10.1007/s11606-020-06506-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 12/17/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patient-centered counseling to help women achieve their reproductive goals is an essential yet often absent component of primary care. OBJECTIVE We developed and piloted MyPath, a novel web-based decision support tool integrating reproductive goals assessment, information about optimizing health before pregnancy, and contraceptive decision support, for use prior to primary care visits in the Veterans Administration (VA). DESIGN We created MyPath using best practices for decision tool development, including a conceptual framework informed by theory and user-centered design with input from patients, providers, and scientific experts. We conducted a non-randomized pilot in two VA Women's Health primary care clinics. A control group (n = 28) was recruited prior to and intervention group (n = 30) recruited after introduction of MyPath into clinics. PARTICIPANTS Women Veterans ages 18-44 with an upcoming visit scheduled with one of eight providers. INTERVENTIONS After recruitment of controls, providers and staff received a brief introduction to MyPath. Patients scheduled to see providers in the intervention phase used MyPath on an iPad in the waiting room prior to their visit. MAIN MEASURES Acceptability, feasibility, discussions about pregnancy and/or contraceptive needs, and contraceptive decision quality by a survey of participants and providers. KEY RESULTS Nearly all participants who used MyPath reported they learned new information (97%) and would recommend it to other Veterans (93%). No providers reported that MyPath significantly increased workload. A greater proportion of intervention participants reported having discussions about reproductive needs in their visit compared to controls (93% vs 68%; p = 0.02). Intervention participants also experienced greater increases in pre-/post-visit knowledge and communication self-efficacy and a trend towards greater reduction in contraceptive decision conflict compared to controls. CONCLUSIONS MyPath was highly acceptable to women, increased the proportion of primary care visits addressing reproductive needs, and improved decision quality without increasing providers' perceived workload. A larger randomized evaluation of effectiveness is warranted.
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Affiliation(s)
- Lisa S Callegari
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.
- Department of Obstetrics & Gynecology, University of Washington School of Medicine, Seattle, WA, USA.
- Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA.
| | - Karin M Nelson
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - David E Arterburn
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Christine Dehlendorf
- Department of Family Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Sara L Magnusson
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
| | - Samantha K Benson
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
| | - E Bimla Schwarz
- Department of Medicine, University of California, Davis, Davis, CA, USA
| | - Sonya Borrero
- Center for Health Equity, Research, and Promotion, VA Pittsburgh Health Care System, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Park YHA, Keller A, Hsu TCM, Bidassie B, Venne V, Hawley D, Hoffman-Högg L, Heron B, Colonna S, Aggarwal A. Screening High-Risk Women Veterans for Breast Cancer. Fed Pract 2021; 38:S35-S41. [PMID: 34177240 PMCID: PMC8223736 DOI: 10.12788/fp.0122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Within the US Department of Veterans Affairs (VA), breast cancer prevalence has more than tripled from 1995 to 2012. Women veterans may be at an increased breast cancer risk based on service-related exposures and posttraumatic stress disorder (PTSD). METHODS Women veterans aged ≥ 35 years with no personal history of breast cancer were enrolled at 2 urban VA medical centers. We surveyed women veterans for 5-year and lifetime risks of invasive breast cancer using the Gail Breast Cancer Risk Assessment Tool (BCRAT). Data regarding demographics, PTSD status, eligibility for chemoprevention, and genetic counseling were also collected. Descriptive statistics were used to determine results. RESULTS A total of 99 women veterans participated, of which 60% were Black. In total, 35% were high risk with a 5-year BCRAT > 1.66%. Breast biopsies had been performed in 22% of our entire population; 57% had a family history positive for breast cancer. Comparatively, in our high-risk Black population, 33% had breast biopsies and 94% had a family history. High-risk patients were referred for chemoprevention; 5 accepted and 13 were referred for genetic counseling. PTSD was present in 31% of the high-risk subgroup. CONCLUSIONS A high percentage of Black patients participated in this pilot study, which also showed an above average rate of PTSD among women veterans who are at high risk for developing breast cancer. Historically, breast cancer rates among Black women are lower than those found in the general population. High participation among Black women veterans in this pilot study uncovered the potential for further study of this population, which is otherwise underrepresented in research. Limitations included a small sample size, exclusively urban population, and self-selection for screening. Future directions include the evaluation of genetic and molecular mutations in high risk Black women veterans, possibly even a role for PTSD epigenetic changes.
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Affiliation(s)
- Yeun-Hee Anna Park
- is Chief of Hematology/Oncology; is a Research Coordinator; and is a Research Nurse Practitioner, all at James J. Peters Veterans Affairs Medical Center, Bronx, New York. is an Industrial Engineer VA Center for Applied Systems Engineering (VA-CASE), VISN11 - Veterans Engineering Resource Center (VERC) at Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana. was a Senior Genetic Counselor for the US Department of Veterans Affairs (VA) Genomic Medicine Services, and is a Hematologist/Oncologist; both at George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah. is a Hematologist/Oncologist at Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio. is a ONS Clinical Nurse Advisor for the Oncology Field Advisory Committee and VHA National Program Manager for Prevention Policy at Veterans Health Administration (VHA) National Center for Health Promotion and Disease Prevention, Durham, North Carolina and VHA Office of Nursing Services, Washington, DC. is a Program Manager at Veterans Health Administration, Pharmacy Benefits Management Services in Hines, Illinois. is a Hematologist/Oncologist Washington Veterans Affairs Medical Center, Washington, DC
| | - Alison Keller
- is Chief of Hematology/Oncology; is a Research Coordinator; and is a Research Nurse Practitioner, all at James J. Peters Veterans Affairs Medical Center, Bronx, New York. is an Industrial Engineer VA Center for Applied Systems Engineering (VA-CASE), VISN11 - Veterans Engineering Resource Center (VERC) at Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana. was a Senior Genetic Counselor for the US Department of Veterans Affairs (VA) Genomic Medicine Services, and is a Hematologist/Oncologist; both at George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah. is a Hematologist/Oncologist at Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio. is a ONS Clinical Nurse Advisor for the Oncology Field Advisory Committee and VHA National Program Manager for Prevention Policy at Veterans Health Administration (VHA) National Center for Health Promotion and Disease Prevention, Durham, North Carolina and VHA Office of Nursing Services, Washington, DC. is a Program Manager at Veterans Health Administration, Pharmacy Benefits Management Services in Hines, Illinois. is a Hematologist/Oncologist Washington Veterans Affairs Medical Center, Washington, DC
| | - Ta-Chueh Melody Hsu
- is Chief of Hematology/Oncology; is a Research Coordinator; and is a Research Nurse Practitioner, all at James J. Peters Veterans Affairs Medical Center, Bronx, New York. is an Industrial Engineer VA Center for Applied Systems Engineering (VA-CASE), VISN11 - Veterans Engineering Resource Center (VERC) at Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana. was a Senior Genetic Counselor for the US Department of Veterans Affairs (VA) Genomic Medicine Services, and is a Hematologist/Oncologist; both at George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah. is a Hematologist/Oncologist at Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio. is a ONS Clinical Nurse Advisor for the Oncology Field Advisory Committee and VHA National Program Manager for Prevention Policy at Veterans Health Administration (VHA) National Center for Health Promotion and Disease Prevention, Durham, North Carolina and VHA Office of Nursing Services, Washington, DC. is a Program Manager at Veterans Health Administration, Pharmacy Benefits Management Services in Hines, Illinois. is a Hematologist/Oncologist Washington Veterans Affairs Medical Center, Washington, DC
| | - Balmatee Bidassie
- is Chief of Hematology/Oncology; is a Research Coordinator; and is a Research Nurse Practitioner, all at James J. Peters Veterans Affairs Medical Center, Bronx, New York. is an Industrial Engineer VA Center for Applied Systems Engineering (VA-CASE), VISN11 - Veterans Engineering Resource Center (VERC) at Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana. was a Senior Genetic Counselor for the US Department of Veterans Affairs (VA) Genomic Medicine Services, and is a Hematologist/Oncologist; both at George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah. is a Hematologist/Oncologist at Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio. is a ONS Clinical Nurse Advisor for the Oncology Field Advisory Committee and VHA National Program Manager for Prevention Policy at Veterans Health Administration (VHA) National Center for Health Promotion and Disease Prevention, Durham, North Carolina and VHA Office of Nursing Services, Washington, DC. is a Program Manager at Veterans Health Administration, Pharmacy Benefits Management Services in Hines, Illinois. is a Hematologist/Oncologist Washington Veterans Affairs Medical Center, Washington, DC
| | - Vickie Venne
- is Chief of Hematology/Oncology; is a Research Coordinator; and is a Research Nurse Practitioner, all at James J. Peters Veterans Affairs Medical Center, Bronx, New York. is an Industrial Engineer VA Center for Applied Systems Engineering (VA-CASE), VISN11 - Veterans Engineering Resource Center (VERC) at Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana. was a Senior Genetic Counselor for the US Department of Veterans Affairs (VA) Genomic Medicine Services, and is a Hematologist/Oncologist; both at George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah. is a Hematologist/Oncologist at Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio. is a ONS Clinical Nurse Advisor for the Oncology Field Advisory Committee and VHA National Program Manager for Prevention Policy at Veterans Health Administration (VHA) National Center for Health Promotion and Disease Prevention, Durham, North Carolina and VHA Office of Nursing Services, Washington, DC. is a Program Manager at Veterans Health Administration, Pharmacy Benefits Management Services in Hines, Illinois. is a Hematologist/Oncologist Washington Veterans Affairs Medical Center, Washington, DC
| | - Douglas Hawley
- is Chief of Hematology/Oncology; is a Research Coordinator; and is a Research Nurse Practitioner, all at James J. Peters Veterans Affairs Medical Center, Bronx, New York. is an Industrial Engineer VA Center for Applied Systems Engineering (VA-CASE), VISN11 - Veterans Engineering Resource Center (VERC) at Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana. was a Senior Genetic Counselor for the US Department of Veterans Affairs (VA) Genomic Medicine Services, and is a Hematologist/Oncologist; both at George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah. is a Hematologist/Oncologist at Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio. is a ONS Clinical Nurse Advisor for the Oncology Field Advisory Committee and VHA National Program Manager for Prevention Policy at Veterans Health Administration (VHA) National Center for Health Promotion and Disease Prevention, Durham, North Carolina and VHA Office of Nursing Services, Washington, DC. is a Program Manager at Veterans Health Administration, Pharmacy Benefits Management Services in Hines, Illinois. is a Hematologist/Oncologist Washington Veterans Affairs Medical Center, Washington, DC
| | - Lori Hoffman-Högg
- is Chief of Hematology/Oncology; is a Research Coordinator; and is a Research Nurse Practitioner, all at James J. Peters Veterans Affairs Medical Center, Bronx, New York. is an Industrial Engineer VA Center for Applied Systems Engineering (VA-CASE), VISN11 - Veterans Engineering Resource Center (VERC) at Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana. was a Senior Genetic Counselor for the US Department of Veterans Affairs (VA) Genomic Medicine Services, and is a Hematologist/Oncologist; both at George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah. is a Hematologist/Oncologist at Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio. is a ONS Clinical Nurse Advisor for the Oncology Field Advisory Committee and VHA National Program Manager for Prevention Policy at Veterans Health Administration (VHA) National Center for Health Promotion and Disease Prevention, Durham, North Carolina and VHA Office of Nursing Services, Washington, DC. is a Program Manager at Veterans Health Administration, Pharmacy Benefits Management Services in Hines, Illinois. is a Hematologist/Oncologist Washington Veterans Affairs Medical Center, Washington, DC
| | - Bernadette Heron
- is Chief of Hematology/Oncology; is a Research Coordinator; and is a Research Nurse Practitioner, all at James J. Peters Veterans Affairs Medical Center, Bronx, New York. is an Industrial Engineer VA Center for Applied Systems Engineering (VA-CASE), VISN11 - Veterans Engineering Resource Center (VERC) at Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana. was a Senior Genetic Counselor for the US Department of Veterans Affairs (VA) Genomic Medicine Services, and is a Hematologist/Oncologist; both at George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah. is a Hematologist/Oncologist at Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio. is a ONS Clinical Nurse Advisor for the Oncology Field Advisory Committee and VHA National Program Manager for Prevention Policy at Veterans Health Administration (VHA) National Center for Health Promotion and Disease Prevention, Durham, North Carolina and VHA Office of Nursing Services, Washington, DC. is a Program Manager at Veterans Health Administration, Pharmacy Benefits Management Services in Hines, Illinois. is a Hematologist/Oncologist Washington Veterans Affairs Medical Center, Washington, DC
| | - Sarah Colonna
- is Chief of Hematology/Oncology; is a Research Coordinator; and is a Research Nurse Practitioner, all at James J. Peters Veterans Affairs Medical Center, Bronx, New York. is an Industrial Engineer VA Center for Applied Systems Engineering (VA-CASE), VISN11 - Veterans Engineering Resource Center (VERC) at Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana. was a Senior Genetic Counselor for the US Department of Veterans Affairs (VA) Genomic Medicine Services, and is a Hematologist/Oncologist; both at George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah. is a Hematologist/Oncologist at Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio. is a ONS Clinical Nurse Advisor for the Oncology Field Advisory Committee and VHA National Program Manager for Prevention Policy at Veterans Health Administration (VHA) National Center for Health Promotion and Disease Prevention, Durham, North Carolina and VHA Office of Nursing Services, Washington, DC. is a Program Manager at Veterans Health Administration, Pharmacy Benefits Management Services in Hines, Illinois. is a Hematologist/Oncologist Washington Veterans Affairs Medical Center, Washington, DC
| | - Anita Aggarwal
- is Chief of Hematology/Oncology; is a Research Coordinator; and is a Research Nurse Practitioner, all at James J. Peters Veterans Affairs Medical Center, Bronx, New York. is an Industrial Engineer VA Center for Applied Systems Engineering (VA-CASE), VISN11 - Veterans Engineering Resource Center (VERC) at Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana. was a Senior Genetic Counselor for the US Department of Veterans Affairs (VA) Genomic Medicine Services, and is a Hematologist/Oncologist; both at George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah. is a Hematologist/Oncologist at Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio. is a ONS Clinical Nurse Advisor for the Oncology Field Advisory Committee and VHA National Program Manager for Prevention Policy at Veterans Health Administration (VHA) National Center for Health Promotion and Disease Prevention, Durham, North Carolina and VHA Office of Nursing Services, Washington, DC. is a Program Manager at Veterans Health Administration, Pharmacy Benefits Management Services in Hines, Illinois. is a Hematologist/Oncologist Washington Veterans Affairs Medical Center, Washington, DC
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Attitudes, Practices, and Experiences with Implementing a Patient-Centered Medical Home for Women Veterans. Womens Health Issues 2017; 27:221-227. [PMID: 28087130 DOI: 10.1016/j.whi.2016.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 10/31/2016] [Accepted: 11/30/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Despite the growing demand for health care among women veterans in the Veterans Health Administration (VHA), little is known about the perspectives of primary care providers (PCPs) and other primary care staff about the care they provide to women veterans. We sought to understand whether barriers to, attitudes about, and practices in caring for women veterans were associated with two measures of implementation of the VHA patient-centered medical home for women veterans (self-efficacy and satisfaction). METHODS We administered a cross-sectional survey by Internet from September 8, 2014, through April 27, 2015 (and by mail from December 16, 2014, through June 18, 2015) to all PCPs and affiliated primary care staff in 12 VHA medical centers. We used descriptive and bivariate analyses to characterize their barriers, attitudes, and practices regarding care for women veterans; and ordinary least squares regression to identify associations with satisfaction and self-efficacy regarding medical home implementation for women veterans among members of a VHA patient-centered medical home teamlet for women patients. RESULTS Of 775 surveys sent, 288 were completed (94 PCPs and 194 staff) for a response rate of 37% (33% for PCPs; 39% for staff). On average, providers had one female patient for every five patients in their panels. Lower perceived barriers, higher gender-sensitive attitudes, and being a PCP were significantly associated with satisfaction and self-efficacy of patient-centered medical home for women patients. CONCLUSIONS Training efforts focused on eliminating perceived barriers and strengthening positive attitudes toward women may be more successful than changing women's health practice characteristics alone.
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Comparing VA and Non-VA Quality of Care: A Systematic Review. J Gen Intern Med 2017; 32:105-121. [PMID: 27422615 PMCID: PMC5215146 DOI: 10.1007/s11606-016-3775-2] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 04/28/2016] [Accepted: 06/07/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND The Veterans Affairs (VA) health care system aims to provide high-quality medical care to veterans in the USA, but the quality of VA care has recently drawn the concern of Congress. The objective of this study was to systematically review published evidence examining the quality of care provided at VA health care facilities compared to quality of care in other facilities and systems. METHODS Building on the search strategy and results of a prior systematic review, we searched MEDLINE (from January 1, 2005, to January 1, 2015) to identify relevant articles on the quality of care at VA facilities compared to non-VA facilities. Articles from the prior systematic review published from 2005 and onward were also included and re-abstracted. Studies were classified, analyzed, and summarized by the Institute of Medicine's quality dimensions. RESULTS Sixty-nine articles were identified (including 31 articles from the prior systematic review and 38 new articles) that address one or more Institute of Medicine quality dimensions: safety (34 articles), effectiveness (24 articles), efficiency (9 articles), patient-centeredness (5 articles), equity (4 articles), and timeliness (1 article). Studies of safety and effectiveness indicated generally better or equal performance, with some exceptions. Too few articles related to timeliness, equity, efficiency, and patient-centeredness were found from which to reliably draw conclusions about VA care related to these dimensions. DISCUSSION The VA often (but not always) performs better than or similarly to other systems of care with regard to the safety and effectiveness of care. Additional studies of quality of care in the VA are needed on all aspects of quality, but particularly with regard to timeliness, equity, efficiency, and patient-centeredness.
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Reddy SM, Rose DE, Burgess JF, Charns MP, Yano EM. The Role of Organizational Factors in the Provision of Comprehensive Women's Health in the Veterans Health Administration. Womens Health Issues 2016; 26:648-655. [PMID: 27745998 DOI: 10.1016/j.whi.2016.09.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 08/15/2016] [Accepted: 09/01/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Increasing numbers of women veterans present an organizational challenge to a health care system that historically has served men. Women veterans require comprehensive women's health services traditionally not provided by the Veterans Health Administration. OBJECTIVE Examine the association of organizational factors and adoption of comprehensive women's health care. STUDY DESIGN Cross-sectional analysis of the 2007 Veterans Health Administration National Survey of Women Veterans Health Programs and Practices. METHODS Dependent measures included a) model of women's health care: separate women's health clinic (WHC), designated women's health provider in primary care (DWHP), both (WHC+DWHP), or neither and b) the availability of five women's health services: cervical cancer screening and evaluation and management of vaginitis, menstrual disorders, contraception, and menopause. Exposure variables were organizational factors drawn from the Greenhalgh model of diffusion of innovations including measures of structure, absorptive capacity, and system readiness for innovation. RESULTS The organizational factors of a gynecology clinic, an academic affiliation with a medical school, a women's health representative on one or more high-impact committees, and a greater caseload of women veterans were more common at sites with WHCs and WHC+DWHPs, compared with sites relying on general primary care with or without a DWHP. Academic affiliation and high-impact committee involvement remained significant in multivariable analysis. Sites with WHCs or WHC+DWHPs were more likely to offer all five women's health services. CONCLUSION Facilities with greater apparent absorptive capacity (academic affiliation and women's health representation on high-impact committees) are more likely to adopt WHCs. Facilities with separate WHCs are more likely to deliver a package of women's health services, promoting comprehensive care for women veterans.
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Affiliation(s)
- Shivani M Reddy
- Department of General Internal Medicine, VA Boston Healthcare System, Boston, Massachusetts; Center for Advanced Methods Development, RTI International, Waltham, Massachusetts.
| | - Danielle E Rose
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, California
| | - James F Burgess
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts; Department of Health Policy & Management, Boston University School of Public Health, Boston, Massachusetts
| | - Martin P Charns
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts; Department of Health Policy & Management, Boston University School of Public Health, Boston, Massachusetts
| | - Elizabeth M Yano
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, California
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Providers' perceptions of barriers and facilitators to disclosure of alcohol use by women veterans. Prim Health Care Res Dev 2016; 18:64-72. [PMID: 27692026 DOI: 10.1017/s1463423616000384] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Aim To better understand barriers and facilitators that hinder or help women veterans discuss their alcohol use with providers in primary care in order to better identify problematic drinking and enhance provider-patient communication about harmful drinking. BACKGROUND Women presenting to primary care may be less likely than men to disclose potentially harmful alcohol use. No studies have qualitatively examined the perspectives of primary care providers about factors that affect accurate disclosure of alcohol use by women veterans during routine clinic visits. METHODS Providers (n=14) were recruited from primary care at two veterans Administration Women's Health Clinics in California, United States. An open-ended interview guide was developed from domains of the consolidated framework for implementation science. Interviews elicited primary care providers' perspectives on barriers and facilitators to women veterans' (who may or may not be using alcohol in harmful ways) disclosure of alcohol use during routine clinic visits. Interview data were analyzed deductively using a combination of template analysis and matrix analysis. Findings Participants reported six barriers and five facilitators that they perceived affect women veteran's decision to accurately disclose alcohol use during screenings and openness to discussing harmful drinking with a primary care provider. The most commonly described barriers to disclosure were stigma, shame, and discomfort, and co-occuring mental health concerns, while building strong therapeutic relationships and using probes to 'dig deeper' were most often described as facilitators. Findings from this study may enhance provider-patient discussions about alcohol use and help primary care providers to better identify problematic drinking among women veterans, ultimately improving patient outcomes.
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11
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Special Services for Women in Substance Use Disorders Treatment: How Does the Department of Veterans Affairs Compare with Other Providers? Womens Health Issues 2015; 25:666-72. [PMID: 26329259 DOI: 10.1016/j.whi.2015.07.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 05/21/2015] [Accepted: 07/06/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Gender is an important consideration in the treatment of substance use disorders (SUD). Although the number of women seeking care through the Department of Veterans Affairs (VA) has increased dramatically, little is known about the capacity of the VA to meet the needs of women with SUD. We examined the prevalence of programs and key services for women in VA facilities in a survey of 14,311 SUD treatment facilities. METHODS Using data from the 2012 National Survey of Substance Abuse Treatment Services, we calculated the percent of VA facilities offering special programs or groups exclusively for women, compared with facilities under other types of ownership. For each ownership type, we also calculated the mean number of ancillary services offered that are critical for many women in SUD treatment, including child care, domestic violence counseling, and transportation assistance. Multivariable models were used to adjust for differences in other facility characteristics. FINDINGS Approximately 31% of facilities had special programs exclusively for women. The VA had the lowest prevalence of programs for women, at 19.1%; however, the VA offered an average of 5 key services for women, which was significantly higher than the averages for other federal (n = 2), local (n = 4), and private for-profit (n = 2) facilities. Results were generally robust to multivariable adjustments. CONCLUSIONS The VA should consider developing more SUD programs and groups exclusively for women, while maintaining ancillary services at their relatively abundant level. Gender-specific programs and groups could serve as points of referral to ancillary services for women veterans.
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12
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Women with breast cancer in the Veterans Health Administration: demographics, breast cancer characteristics, and trends. Med Care 2015; 53:S149-55. [PMID: 25767969 DOI: 10.1097/mlr.0000000000000299] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
An increasing number of women are being cared for within the Veterans Health Administration (VA). However, the demographics and trends of women with breast cancer at the VA has not been documented. We describe the demographics and breast cancer characteristics of the 4445 women enrolled in the VA and reported to the Department of Veterans Affairs Central Cancer Registry diagnosed with breast cancer from 1995 to 2012. The cases of breast cancer per year increased over time to 365 in 2012. Black women represented only 16% of women diagnosed with breast cancer in the VA in 1995-1999 but increased to 25% by 2010-2012 (P<0.001). The median age at diagnosis in 1995-1999 was 58.4 and decreased to 56.8 by 2010-2012 (P<0.02). The fraction of breast cancers that were node negative was 45% in 1995-1999 and increased to 64% in 2010-2012; correspondingly, women presented at an earlier stage in more recent years (P<0.001). Urban women with breast cancer cared for within the VA are more likely to be younger (P=0.04) and nonwhite (P<0.001) compared with rural women, but the breast tumor characteristics appear similar. Oncology physicians at the VA must be prepared to care for breast cancer among women as the number of cases is growing. With only 365 women diagnosed with breast cancer at the VA as per year 2012 and nearly 150 treating VA facilities, the number of breast cancer patients seen by a particular physician could be quite low, and this fact suggests a need for an evaluation of the quality and outcomes of breast cancer care at the VA.
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13
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Readying the workforce: evaluation of VHA's comprehensive women's health primary care provider initiative. Med Care 2015; 53:S39-46. [PMID: 25767974 DOI: 10.1097/mlr.0000000000000298] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Veterans Health Administration (VHA) primary care providers (PCPs) often see few women, making it challenging to maintain proficiency in women's health (WH). Therefore, VHA in 2010 established Designated WH Providers, who would maintain proficiency in comprehensive WH care and be preferentially assigned women patients. OBJECTIVE To evaluate early implementation of this national policy. METHODS At each VHA health care system (N=140), the Women Veterans Program Manager completed a Fiscal Year 2012 workforce capacity assessment (response rate, 100%), representing the first time the national Designated WH Provider workforce had been identified. Assessment data were linked to administrative data. RESULTS Of all VHA PCPs, 23% were Designated WH Providers; 100% of health care systems and 83% of community clinics had at least 1 Designated WH Provider. On average, women veterans comprised 19% (SD=27%) of the patients Designated WH Providers saw in primary care, versus 5% (SD=7%) for Other PCPs (P<0.001). For women veterans using primary care (N=313,033), new patients were less likely to see a Designated WH Provider than established women veteran patients (52% vs. 64%; P<0.001). CONCLUSIONS VHA has achieved its goal of a Designated WH Provider in every health care system, and is approaching its goal of a Designated WH Provider at every hospital/community clinic. Designated WH Providers see more women than do Other PCPs. However, as the volume of women patients remains low for many providers, attention to alternative approaches to maintaining proficiency may prove necessary, and barriers to assigning new women patients to Designated WH Providers merit attention.
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deKleijn M, Lagro-Janssen AL, Canelo I, Yano EM. Creating a roadmap for delivering gender-sensitive comprehensive care for women Veterans: results of a national expert panel. Med Care 2015; 53:S156-64. [PMID: 25767971 PMCID: PMC4379113 DOI: 10.1097/mlr.0000000000000307] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Women Veterans are a significant minority of users of the VA healthcare system, limiting provider and staff experience meeting their needs in environments historically designed for men. The VA is nonetheless committed to ensuring that women Veterans have access to comprehensive care in environments sensitive to their needs. OBJECTIVES We sought to determine what aspects of care need to be tailored to the needs of women Veterans in order for the VA to deliver gender-sensitive comprehensive care. RESEARCH DESIGN Modified Delphi expert panel process. SUBJECTS Eleven clinicians and social scientists with expertise in women's health, primary care, and mental health. MEASURES Importance of tailoring over 100 discrete aspects of care derived from the Institute of Medicine's definition of comprehensive care and literature-based domains of sex-sensitive care on a 5-point scale. RESULTS Panelists rated over half of the aspects of care as very-to-extremely important (median score 4+) to tailor to the needs of women Veterans. The panel arrived at 14 priority recommendations that broadly encompassed the importance of (1) the design/delivery of services sensitive to trauma histories, (2) adapting to women's preferences and information needs, and (3) sex awareness and cultural transformation in every facet of VA operations. CONCLUSIONS We used expert panel methods to arrive at consensus on top priority recommendations for improving delivery of sex-sensitive comprehensive care in VA settings. Accomplishment of their breadth will require national, regional, and local strategic action and multilevel stakeholder engagement, and will support VA's national efforts at improving customer service for all Veterans.
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Affiliation(s)
- Miriam deKleijn
- Department of Primary and Community Care, Gender and Women's Health Unit, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Antoine L.M. Lagro-Janssen
- Department of Primary and Community Care, Gender and Women's Health Unit, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ismelda Canelo
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles, Sepulveda
| | - Elizabeth M. Yano
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles, Sepulveda
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA
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15
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Bean-Mayberry B, Bastian L, Trentalange M, Murphy TE, Skanderson M, Allore H, Reyes-Harvey E, Maisel NC, Gaetano V, Wright S, Haskell S, Brandt C. Associations between provider designation and female-specific cancer screening in women Veterans. Med Care 2015; 53:S47-54. [PMID: 25767975 PMCID: PMC5477654 DOI: 10.1097/mlr.0000000000000323] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In 2010, the Department of Veterans Affairs Healthcare System (VA) implemented policy to provide Comprehensive Primary Care (for acute, chronic, and female-specific care) from designated Women's Health providers (DWHPs) at all VA sites. However, since that time no comparisons of quality measures have been available to assess the level of care for women Veterans assigned to these providers. OBJECTIVES To evaluate the associations between cervical and breast cancer screening rates among age-appropriate women Veterans and designation of primary-care provider (DWHP vs. non-DWHP). RESEARCH DESIGN Cross-sectional analyses using the fiscal year 2012 data on VA women's health providers, administrative files, and patient-specific quality measures. SUBJECTS The sample included 37,128 women Veterans aged 21 through 69 years. MEASURES Variables included patient demographic and clinical factors (ie, age, race, ethnicity, mental health diagnoses, obesity, and site), and provider factors (ie, DWHP status, sex, and panel size). Screening measures were defined by age-appropriate subgroups using VA national guidelines. RESULTS Female-specific cancer screening rates were higher among patients assigned to DWHPs (cervical cytology 94.4% vs. 91.9%, P<0.0001; mammography 86.3% vs. 83.3%, P<0.0001). In multivariable models with adjustment for patient and provider characteristics, patients assigned to DWHPs had higher odds of cervical cancer screening (odds ratio, 1.26; 95% confidence interval, 1.07-1.47; P<0.0001) and breast cancer screening (odds ratio, 1.24; 95% CI, 1.10-1.39; P<0.0001). CONCLUSIONS As the proportion of women Veterans increases, assignment to DWHPs may raise rate of female-specific cancer screening within VA. Separate evaluation of sex neutral measures is needed to determine whether other measures accrue benefits for patients with DWHPs.
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Affiliation(s)
- Bevanne Bean-Mayberry
- VA Greater Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA
| | - Lori Bastian
- VA Connecticut Healthcare System, West Haven
- Department of Internal Medicine, University of Connecticut Health Center, Farmington
| | - Mark Trentalange
- Department of Internal Medicine, School of Medicine, New Haven, CT
| | | | | | - Heather Allore
- Department of Internal Medicine, School of Medicine, New Haven, CT
| | | | - Natalya C. Maisel
- VA Palo Alto Health Care System, HSR&D Center for Innovation to Implementation (Ci2i), Palo Alto, CA
| | - Vera Gaetano
- VA Connecticut HSR&D Pain, Research, Informatics, Multimorbidities, and Education (Prime) Center, West Haven, CT
| | - Steven Wright
- Office of Analytics & Business Intelligence (10P2B), Durham, NC
| | - Sally Haskell
- VA Connecticut Healthcare System, West Haven
- Department of Internal Medicine, School of Medicine, New Haven, CT
- Women’s Health Services, Patient Care Services, VA Central Office, Washington, DC
| | - Cynthia Brandt
- VA Connecticut Healthcare System, West Haven
- Yale University School of Medicine, Yale Center for Medical Informatics, West Haven, CT
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Ryan GL, Mengeling MA, Booth BM, Torner JC, Syrop CH, Sadler AG. Voluntary and involuntary childlessness in female veterans: associations with sexual assault. Fertil Steril 2014; 102:539-47. [PMID: 24875400 DOI: 10.1016/j.fertnstert.2014.04.042] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 04/25/2014] [Accepted: 04/25/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To assess associations between lifetime sexual assault and childlessness in female veterans. DESIGN Cross-sectional, computer-assisted telephone interview study. SETTING Two Midwestern Veterans Administration (VA) medical centers. PATIENT(S) A total of 1,004 women aged ≤52 years, VA-enrolled between 2000 and 2008. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Sociodemographic variables, reproductive history and care utilization, and mental health. RESULT(S) A total of 620 veterans (62%) reported at least one attempted or completed sexual assault in their lifetime (LSA). Veterans with LSA more often self-reported a history of pregnancy termination (31% vs. 19%) and infertility (23% vs. 12%), as well as sexually transmitted infection (42% vs. 27%), posttraumatic stress disorder (32% vs. 10%), and postpartum dysphoria (62% vs. 44%). Lifetime sexual assault was independently associated with termination and infertility in multivariate models; sexually transmitted infection, posttraumatic stress disorder, and postpartum dysphoria were not. The LSA by period of life was as follows: 41% of participants in childhood, 15% in adulthood before the military, 33% in military, and 13% after the military (not mutually exclusive). Among the 511 who experienced a completed LSA, 23% self-reported delaying or foregoing pregnancy because of their assault. CONCLUSION(S) This study demonstrated associations between sexual assault history and pregnancy termination, delay or avoidance (voluntary childlessness), and infertility (involuntary childlessness) among female veterans. Improved gender-specific veteran medical care must attend to these reproductive complexities.
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Affiliation(s)
- Ginny L Ryan
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa.
| | - Michelle A Mengeling
- Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa; Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa; VA Office of Rural Health, Veterans Rural Health Resource Center-Central Region, Iowa City VA Health care System, Iowa City, Iowa
| | - Brenda M Booth
- Center for Mental Healthcare Outcomes and Research, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas; Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - James C Torner
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa; Department of Neurosurgery and Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Craig H Syrop
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Anne G Sadler
- Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa; Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa
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Wooten NR, Mohr BA, Lundgren LM, Adams RS, Merrick EL, Williams TV, Larson MJ. Gender differences in substance use treatment utilization in the year prior to deployment in Army service members. J Subst Abuse Treat 2013; 45:257-65. [PMID: 23726826 PMCID: PMC3755744 DOI: 10.1016/j.jsat.2013.04.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Revised: 02/24/2013] [Accepted: 04/04/2013] [Indexed: 01/15/2023]
Abstract
Although military men have heavier drinking patterns, military women experience equal or higher rates of dependence symptoms and similar rates of alcohol-related problems as men at lower levels of consumption. Thus, gender may be important for understanding substance use treatment (SUT) utilization before deployment. Military health system data were analyzed to examine gender differences in both substance use diagnosis (SUDX) and SUT in 152,447 Army service members returning from deployments in FY2010. Propensity score analysis of probability of SUDX indicated that women had lower odds (AOR: 0.91, 95% CI: 0.86-0.96) of military lifetime SUDX. After adjusting for lifetime SUDX using propensity score analysis, multivariate regression found women had substantially lower odds (AOR: 0.61; 95% CI: 0.54-0.70) of using SUT the year prior to deployment. Findings suggest gender disparities in military-provided SUT and a need to consider whether military substance use assessment protocols are sensitive to gender differences.
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Affiliation(s)
- Nikki R Wooten
- University of South Carolina, College of Social Work, Columbia, SC 29208, USA.
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Sered S, Norton-Hawk M. Criminalized women and the health care system: the case for continuity of services. JOURNAL OF CORRECTIONAL HEALTH CARE 2013; 19:164-77. [PMID: 23711803 DOI: 10.1177/1078345813486323] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Drawing upon research with criminalized women in Massachusetts, this article examines barriers to health care before, during, and after incarceration. Although very few of the surveyed women reported having had to forgo medical treatment because of an inability to pay, almost all of them reported being unable to access consistent, ongoing health care services. Typically, the women recalled sequential contact with dozens of providers at dozens of facilities, treatment plans that had been developed but never executed, psychotherapy that opened wounds but was terminated before healing them, and involuntary interruptions in legally prescribed courses of psychiatric medications. Acknowledging that these problems are related to wider structures of health care delivery in the United States, this article ends with a modest proposal for developing a role for health care advocates assigned to coordinate care for those with complicated medical problems to help them manage their health care needs over a long period of time.
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Affiliation(s)
- Susan Sered
- Department of Sociology, Suffolk University, Boston, MA 02108, USA.
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Borrero S, Mor MK, Zhao X, McNeil M, Ibrahim S, Hayes P. Contraceptive care in the VA health care system. Contraception 2012; 85:580-8. [DOI: 10.1016/j.contraception.2011.10.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Revised: 10/17/2011] [Accepted: 10/19/2011] [Indexed: 10/14/2022]
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20
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MacGregor C, Hamilton AB, Oishi SM, Yano EM. Description, development, and philosophies of mental health service delivery for female veterans in the VA: a qualitative study. Womens Health Issues 2011; 21:S138-44. [PMID: 21724133 DOI: 10.1016/j.whi.2011.04.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Revised: 04/15/2011] [Accepted: 04/18/2011] [Indexed: 11/16/2022]
Abstract
PURPOSE National Veterans Health Administration (VA) organizational data suggested the presence of separate and formal mental health services for female veterans, prompting qualitative exploration of their structure and development. METHODS Semistructured telephone interviews were conducted with a purposeful sample of 36 VA mental health administrators and providers from 26 VA Medical Centers and large community-based outpatient clinics that reported having separate women's mental health clinics and/or designated women's mental health providers in their outpatient mental health clinics. MAIN FINDINGS VA facilities have implemented a spectrum of women's mental health service delivery arrangements, including specialized mental health providers, co-located mental health providers in women's health clinics, women-only mental health groups, and women's mental health clinics. Most facilities had one or more "champions" developing such services, but some faced challenges in maintaining viability. Some respondents expressed concern about possible stigmatization associated with creating separate mental health services for female veterans. CONCLUSION Arrangements of VA mental health services for female veterans vary across facilities. This study identified a lack of consensus in the field regarding the need for and consequences of adapting existing programs specifically for the mental health needs of female veterans. Implementation of VA policy may require greater attention to frontline providers' perspectives. Comparative impact studies of female veterans' mental health service delivery arrangements are also needed.
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Affiliation(s)
- Casey MacGregor
- VA HSR&D Center of Excellence for Study of Healthcare Provider Behavior, Sepulveda, California 91343, USA.
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21
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Washington DL, Bean-Mayberry B, Mitchell MN, Riopelle D, Yano EM. Tailoring VA primary care to women veterans: association with patient-rated quality and satisfaction. Womens Health Issues 2011; 21:S112-9. [PMID: 21724130 DOI: 10.1016/j.whi.2011.04.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 03/26/2011] [Accepted: 04/15/2011] [Indexed: 10/28/2022]
Abstract
BACKGROUND Primary care delivery models tailored to women's needs and preferences are associated with higher quality and satisfaction. Therefore, the U.S. Department of Veterans Affairs (VA) recommends adoption of designated providers for women in primary care clinics or women's health centers as the optimal models for women's primary care. We assessed women veterans' ratings of their VA health care quality, gender-related satisfaction, gender appropriateness, and VA provider skills in treating women, in relation to primary care model at VA sites nationwide. METHODS Health care ratings were obtained from VA users in the 2008-2009 National Survey of Women Veterans. VA administrative data identified the site for each respondent's primary care. Facility data identified the site's primary care model for women. We conducted multilevel modeling to compare health care ratings for sites serving 300 or more women veterans who had adopted VA recommendations for women's primary care models (adopter sites), with non-adopter sites, and with small sites serving fewer women veterans, adjusting for patient characteristics. RESULTS Adopter sites received higher adjusted ratings of gender-related satisfaction and perceptions of VA provider skills than non-adopter and small sites. Adopter sites also received higher adjusted ratings of gender appropriateness than small sites. Adjusted ratings of quality of care did not differ by type of site. CONCLUSION VA sites with primary care models tailored to women were rated higher on most dimensions of care. Facilitating establishment of these optimal care models at other sites is one strategy for improving women veterans' experiences with VA care. Research to identify other features of care associated with quality could inform ongoing VA quality transformation efforts.
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Affiliation(s)
- Donna L Washington
- VA Greater Los Angeles Health Services Research and Development (HSR&D) Center of Excellence, Sepulveda, California, USA.
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22
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Leading the Nation in Women’s Health: The Important Role of Research. Womens Health Issues 2011; 21:S70-2. [DOI: 10.1016/j.whi.2011.04.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Accepted: 04/20/2011] [Indexed: 11/20/2022]
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Bean-Mayberry B, Yano EM, Washington DL, Goldzweig C, Batuman F, Huang C, Miake-Lye I, Shekelle PG. Systematic Review of Women Veterans’ Health: Update on Successes and Gaps. Womens Health Issues 2011; 21:S84-97. [DOI: 10.1016/j.whi.2011.04.022] [Citation(s) in RCA: 111] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Revised: 04/20/2011] [Accepted: 04/20/2011] [Indexed: 11/30/2022]
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Weisman CS, Chuang CH, Scholle SH. Still piecing it together: women's primary care. Womens Health Issues 2011; 20:228-30. [PMID: 20620910 DOI: 10.1016/j.whi.2010.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2010] [Accepted: 05/09/2010] [Indexed: 10/19/2022]
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Davis KJ, Kumar D, Wake MC. Pelvic floor dysfunction: a scoping study exploring current service provision in the UK, interprofessional collaboration and future management priorities. Int J Clin Pract 2010; 64:1661-70. [PMID: 20946271 DOI: 10.1111/j.1742-1241.2010.02509.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Pelvic floor dysfunction (PFD) has a significant socioeconomic and healthcare cost. This study aimed to investigate current service provision for PFD in the UK, highlighting any gaps and areas for improvement to inform future service improvement. METHODS A three-phase design comprised a scoping literature review, consultation survey with frontline practitioners from four key professional groups and an overarching synthesis. An interpretative analytical framework was informed by the concepts of interdisciplinary and interprofessional collaboration. RESULTS Empirical evidence on PFD service provision is limited. No overarching strategic approach to PFD as a single clinical entity in the UK was identified. Two hundred and forty-three medical, nursing and physiotherapy practitioners from different clinical subspecialties participated in the survey. Access and availability to services, models of delivery and individual practice vary widely within and across the disciplines. Time restrictions, mixed professional attitudes, lack of standardisation and low investment priority were identified as major barriers to optimal service provision. Five overlapping areas for improvement are highlighted: access and availability, team working and collaboration, funding and investment, education, training and research, public and professional awareness. CONCLUSIONS Current services are characterised by a fragmented approach with asynchronous delivery, limited investment and poor interprofessional integration. An improved service delivery model has the potential to improve outcomes through better interdisciplinary collaboration and efficient use of resources.
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Affiliation(s)
- K J Davis
- Department of Community and Health Sciences, Consortium for Healthcare Research, City University, London, UK.
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Alexander IM. Emancipatory actions displayed by multi-ethnic women: "Regaining control of my health care". ACTA ACUST UNITED AC 2010; 22:602-11. [PMID: 21054634 DOI: 10.1111/j.1745-7599.2010.00554.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PURPOSE Despite the recognized importance of patient involvement in primary care interactions, little information describing women's needs and expectations for these interactions is available. This participatory action study was based in Critical Action Theory and designed to describe any emancipatory interests that surfaced when eight ethnically diverse women examined their interactions with primary care nurse practitioners (PCNPs) over the course of five successive focus group meetings. DATA SOURCES Focus group meeting transcripts, field notes, interaction notations, seating maps, and first impression summaries. CONCLUSIONS Participants wanted to learn how to "stand up" for themselves in primary care interactions. They believed this could be accomplished by developing a positive sense of self-esteem. Ultimately, they identified the right way to "talk back" to clinicians and created a method for regaining control of their own health care and maintaining equality in interactions with primary care clinicians. IMPLICATIONS FOR PRACTICE Nurse practitioners working in the primary setting are especially well situated to support self-management and foster patient participation by women as they live with chronic disease, engage in health promotion activities, and deal with common symptomatic problems for themselves and their families.
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Affiliation(s)
- Ivy M Alexander
- Yale University School of Nursing, 100 Church Street South, New Haven, Connecticut 06536-0740, USA.
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Bean-Mayberry B, Yano EM, Mor MK, Bayliss NK, Xu X, Fine MJ. Does sex influence immunization status for influenza and pneumonia in older veterans? J Am Geriatr Soc 2009; 57:1427-32. [PMID: 19515114 PMCID: PMC2785130 DOI: 10.1111/j.1532-5415.2009.02316.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To compare the prevalence of influenza and pneumococcal immunization rates according to sex in a national sample of older veterans in the Department of Veterans Affairs (VA) healthcare system. DESIGN Retrospective, cross-sectional. SETTING VA healthcare system. PARTICIPANTS Current VA healthcare system users aged 65 and older eligible for immunization in fiscal years 2001 to 2003 (N=48,424 patient records). MEASUREMENTS Generalized estimating equations were performed to analyze combined chart review and administrative data to determine effect of sex on receipt of influenza and pneumococcal immunizations. RESULTS Unadjusted immunization rates were higher for men than women for influenza (73% vs 69%) and pneumococcal (87% vs 83%) vaccine. Adjusting for demographics, clinical comorbidities, use, and region, women had significantly lower odds of influenza (odds ratio (OR)=0.85, 95% confidence interval (CI=0.79-0.92) and pneumococcal (OR=0.77, 95% CI=0.71-0.84) immunization. CONCLUSION Older female veterans have lower rates of immunization than older male veterans in VA settings. Although VA remains above community levels for immunization, older female veterans will benefit from targeted efforts to increase immunization prevalence.
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Affiliation(s)
- Bevanne Bean-Mayberry
- Veterans Affairs Greater Los Angeles Health Services Research and Development Center of Excellence, Center for Study of Health Care Provider Behavior, Sepulveda, California, USA.
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Campbell BB, Shah S, Gosselin D. Success with men's educational group appointments (MEGA): subjective improvements in patient education. Am J Mens Health 2008; 3:173-8. [PMID: 19477730 DOI: 10.1177/1557988308322815] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Men have a higher age-adjusted death rate from many of the leading causes of death, compared with women. Avoidance of health care and unhealthy behavior contribute to premature death among men. The Lahey Clinic recently initiated a program, the Men's Educational Group Appointment (MEGA), which capitalizes on the potential benefits of group dynamics in an effort to educate men about preventative health. We hypothesized that putting men into a group setting for the educational portion of the visit would improve information exchange and patient learning. During 12 months, 261 men between the ages of 22 and 67 were evaluated. A survey designed to address both patient satisfaction and patients' perceptions regarding how much they learned was administered to all patients following the MEGA session. We identified high patient satisfaction with the MEGA model. This study illustrates the potential utility of the group model for improving patient education regarding health maintenance among men.
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