Overcoming Barriers to Care

The PTSD findings reported in February 2013 were part of a larger examination of results gathered through the National Survey of Women Veterans, the first comprehensive survey of female veterans conducted since 1985. Led by VA researcher Dr. Donna Washington, the survey is aimed in part at discovering what women veterans want from healthcare providers. Along with other studies of how women hope to utilize VHA services, the survey helps demonstrate the VHA’s continuing focus on the issue that launched the Women’s Health Services program in the first place: access to quality care.

It’s not always easy for women veterans to get to a facility that offers the services they need. At least a third of women veteran patients live in rural areas, and among this third, at least two trends have been demonstrated by VA research: First, a higher proportion of them frequently use outpatient services, and second, a moderately higher proportion of them are older women. These findings point to a need for assuring access to gender-sensitive and focused geriatric care in these areas.

One of these is the Specialty Care Access Network-Extension for Community Healthcare Outcomes, or SCAN-ECHO program, which makes use of videoconferencing technology that can link primary care providers from within a service area to a specialist at the medical center. The program has two obvious benefits: It delivers the knowledge rural and other primary care physicians need to provide care not previously available in their communities, and it prevents veterans with chronic conditions and specialized care needs from having to travel to the medical center to receive care

VA has already adopted some organizational changes to address questions of access for women – and for all veterans. One of these is the Specialty Care Access Network-Extension for Community Healthcare Outcomes, or SCAN-ECHO program, which makes use of videoconferencing technology that can link primary care providers from within a service area to a specialist at the medical center. The program has two obvious benefits: It delivers the knowledge rural and other primary care physicians need to provide care not previously available in their communities, and it prevents veterans with chronic conditions and specialized care needs from having to travel to the medical center to receive care

“We have a women’s health research project that deals with this issue, too,” said Lipson, “that’s aimed at providing specialty care services through technology for virtual education, consultation, and ongoing communication – from specialists in women’s health to primary care providers in rural areas and community-based outpatient clinics, for instance – because they may not see as many women, and they probably don’t have the expertise to address gender-specific care. This effort addresses another problem as well: Women don’t want to go to three or four or five different places to get all of their care needs met – but it’s more difficult to have comprehensive services available when you don’t have very many women at a particular site.”

Difficulty of access affects women veterans, but it also affects VA research. Women, due to their minority status within the veteran population and their geographic dispersal, sometimes find it hard to get the services they need. Likewise, the dispersal of women veterans across VA and the limited number of women at some sites pose challenges in doing research. Despite all the recent advances in women’s health research, this problem – recruiting a sufficient number of women for a study at any one facility to get the numbers needed for research – remains one of the biggest challenges facing VA’s women’s health research program.

In June 2013, a team of health researchers led by Dr. Susan Frayne of the VA Palo Alto Health Care System, published a paper that began by offering a classic example of this dilemma: The 2009 administrative data from a median-sized VA medical center revealed that if you wanted to recruit veterans with a diagnosis of coronary artery disease for a study, you could easily identify about 6,000 men who would be eligible but only about 60 women. Heart disease, a VA priority area, is the leading cause of death in women – but to recruit as many women with coronary artery disease as men who met all study criteria, and who would agree to participate, would have required volunteers from multiple, geographically dispersed facilities – probably from 100 VA healthcare facilities.

In 2010, in response to this problem, HSR&D funded the Women’s Health Research Network (WHRN), composed of two elements: the VA Women’s Health Research Consortium and the VA Women’s Health Practice-Based Research Network.

“The research consortium was aimed at building capacity for research on women’s health issues in VA,” said Lipson. “It includes things like mentoring programs, workshops, and cyber-seminars to disseminate research more widely. They help in the initial development and review of research proposals. There are different workgroups in the consortium that deal with priority research areas, people who are interested in, say, mental health or reproductive health, and they may meet once a month or so. The consortium is about sharing information and learning and developing research in priority areas.”

The Practice-Based Research Network is aimed at developing infrastructure that will allow researchers and clinicians to conduct and support more research, in part by increasing access to a larger pool of eligible women veteran participants, but also by building important connections and collaborations among frontline providers, facility administrators and managers, and researchers at VA facilities that will make it possible for research to be done and also lead the way to seeing it implemented into practice. The number of researchers involved in the effort has more than doubled since 2010, Lipson said. “In addition, we started out with four sites, and there are now 37 that really reflect the diversity of the VA,” she said. “Together they represent about 100,000 women veterans, a third of all women veterans using the VA, so that if someone wants to do a research project, they have enough women that they can actually have significant findings. There’s been a lot of growth in research proposals, and consequently we’re really going to learn a lot more about women throughout the country. ”

To accelerate the research-to-practice time line, HSR&D recently launched the CREATE (Collaborative Research to Enhance and Advance Transformation and Excellence) initiative, which encourages HSR&D investigators to collaborate with VA clinicians and policymakers in designing and conducting research on high-priority issues.

This collaboration between VA clinicians and researchers, Lipson said, is not unique to the Practice-Based Research Network. It’s a program component that distinguishes HSR&D’s work. “VA women’s health research effort over this last decade, and certainly the last five years,” Lipson said, “is a model in terms of researchers working with the program offices that actually provide the care – it has directly informed their decisions about how to practice and improve care for women veterans.”

Even though the time frame for translating research into practice is typically long, and the surge in VA women’s health research is relatively new, VA research has had an impact on women’s healthcare in VHA. Over the past decade, HSR&D research has looked at the way VHA organizes and delivers care, and at the variations in women’s healthcare delivery throughout the system. While some VHA facilities, for example, provide women’s primary care in a mixed-gender primary care clinic, others may provide women’s primary care in a separate Comprehensive Women’s Center that co-locates primary care, gynecology, and mental health care for women. “The results of that body of research, which also looked at satisfaction and quality of care,” said Lipson, “have informed some of the policy decisions that have been put into place throughout the VA, through the Women’s Health Services.”

Another recent example of how VA research has shaped policy is the landmark 2007 study demonstrating that “prolonged exposure therapy,” which involves recounting a traumatic event until the emotions associated with it are diminished, was more effective in treating women veterans with PTSD than the “present-centered” treatment most commonly used by VA clinicians. The study compared outcomes to the two treatments among a group of 277 randomly assigned women veterans. As a result of that study, the VA’s Office of Mental Health Services has worked to modify the care approach of clinicians and make prolonged exposure therapy more available to veteran patients throughout the VA.

To accelerate the research-to-practice time line, HSR&D recently launched the CREATE (Collaborative Research to Enhance and Advance Transformation and Excellence) initiative, which encourages HSR&D investigators to collaborate with VA clinicians and policymakers in designing and conducting research on high-priority issues. A CREATE is a group of coordinated research projects conducted in a particular area by independent collaborating investigators and VA partners. Within a CREATE package, individual studies are designed to be complementary; the VA Women Veterans Healthcare CREATE, Lipson explained, is a group of five projects focused specifically on accelerating the implementation of comprehensive care for women veterans. “With these CREATEs,” she said, “we’re hoping to have a greater impact at the end of five years than an individual project might.”

For the women’s health research program, finding solutions to these issues is urgent: Women are currently entering the military in record numbers, accounting for up to 20 percent of all new recruits. “Women are the fastest growing population within VA,” Lipson said, “but they’re still a minority. I think it says a lot about VA that they realize the importance of serving women veterans, and the importance of recognizing groups within that minority – LGBT veterans, racial and ethnic minorities, and rural women. The women’s health research community at VA, all of them – along with VA providers, administrators, and policymakers, are really committed to women veterans and to improving their care and their health.”

This article first appeared in the The Year in Veterans Affairs & Military Medicine 2013-2014 Edition