Women Veterans Health Research

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1 Women Veterans Health Research Elizabeth M. Yano, PhD, MSPH VA Greater Los Angeles HSR&D Center of Excellence UCLA School of Public Health & Linda Lipson, MA Scientific Program Manager, Women s Health, VA HSR&D Service Institute of Medicine Washington DC May 7, 2009

War exponential in numbers Source: Murdoch, et al.

2 Women in the Military Women have always participated in the military By WWII, female nurses roles firmly established Congress lifted 2% cap on women s participation late in Vietnam War exponential in numbers Source: Murdoch, et al., Women and war: What physicians need to know. JGIM, 21:S5-10, 2006.

Women in the Military Women now represent: 15% active duty 20% new

71% w/1+ combat exposure Fastest growing segment of new VA users

Different sociodemographics >60% under age 45, minorities Source:

3 Women in the Military Women now represent: 15% active duty 20% new recruits 17% Reserve/National Guard Equalization of hardships/risks 71% w/1+ combat exposure Fastest growing segment of new VA users Currently 5-7% 5 of VA users, but >40% OEF/OIF market penetration Different sociodemographics >60% under age 45, minorities Source: Murdoch, et al., Women and war: What physicians need to know. JGIM, 21:S5-10, 2006.

4 Women Veterans in VA Significant comorbid physical and mental illness Higher disease burden than female non-vets Comparable disease burden to male vets Greater mental health burden compared to male vets High rates of sexual harassment, abuse, assault Numerical minority creates challenges for VA Historical predominance of men in VA settings Gaps in safety and privacy for women (GAO) Limited gender-specific service availability (GAO) VA providers with little/no exposure to women

5 VA Women s Health Research Agenda: Systematic Review (2004) Most studies are descriptive and observational Stress of military life, health/performance of military/ VA women, health services research and psychiatric conditions (mostly PTSD, sexual trauma) Almost no trials or interventions Very limited information and notable gaps Prevalence of chronic diseases; women veterans preferences, self-reported care needs; utilization patterns; transitions from military-to to-veteran status; quality of care and how to improve quality publications updating review (2009) Source: Goldzweig C, et al. The state of women veterans health research: Results of a systematic review. JGIM. 2006; 21:S82-92.

6 VA Women s Health Research Agenda: Research Priorities & Common Themes Need for data and understanding of women veterans health care needs Target conditions/populations Mental health and substance abuse (e.g., PTSD, stress, addiction, sexual trauma, depression) Chronic diseases (diabetes, infections, auto-immunity, osteoporosis, obesity, arthritis, chronic pain) Reproductive health (fertility, prenatal care, contraception, menopausal issues) Sources: Yano EM, et al. Toward a VA women s health research agenda: Setting evidence-based priorities to improve the health and health care of women veterans. JGIM. 2006;21:S

7 VA Women s Health Research Agenda: Research Priorities & Common Themes Target special populations: Pregnancy and fertility issues Military exposures Returning military and reservists Long term care Homelessness Recent amputees Models of care, organizational factors Women s clinics, designated WH providers Provider competencies/comfort, training, sensitivity Comparisons of VA and community care Sources: Yano EM, et al. Toward a VA women s health research agenda: Setting evidence-based priorities to improve the health and health care of women veterans. JGIM. 2006;21:S

8 VA s Women s Health Research Agenda: Fostering Research Address identified research priorities Build ORD capacity Improved networking, collaborations, mentoring www1.va.gov/resdev/programs/womens_health/ Address methodologic limitations & other barriers Women s Health scientific review enhanced VA women s health & deployment health solicitations Increase visibility/awareness of VA WH research JGIM Special Issue on VA Women s Health Care Listserv, collaboration, mentorship, interest group Sources: Yano EM, et al. Toward a VA women s health research agenda: Setting evidence-based priorities to improve the health and health care of women veterans. JGIM. 2006;21:S

9 Sampling of Research Projects Impact of practice structure on quality of care for women veterans Gender equity in VA quality Chronic physical and mental illness care in women veterans Quality of breast cancer care in VA Fragmentation of care, unmet health care needs Determinants of changes in how VA women s health care is organized

10 Sampling of Research Projects Detection of intimate partner violence Implementation and sustainability of VA women s mental health clinics Evaluation of military sexual trauma (MST) screening and treatment Randomized clinical trial of cognitive-behavioral treatment for PTSD in women Barriers/facilitators to PTSD treatment seeking Alcohol misuse and risk of post-surgical surgical complications and mortality

More VA Women s Health Care Research on OEF/OIF Funded Sexual violence and gynecologic health MST effects on PTSD and behavior among Marines Physical and sexual assault in

11 More VA Women s Health Care Research on OEF/OIF Funded Sexual violence and gynecologic health MST effects on PTSD and behavior among Marines Physical and sexual assault in deployed women: risks, outcomes, services Predicting post-deployment mental health and substance abuse service needs Reintegration and service needs for women veteran mothers

12 More Research Funded to Evaluate Health Care Needs, Access, Barriers Stigma, gender, other barriers to VA care National Survey of Women Veterans Demographics, health care needs, VA experiences Differences by periods of military service Preferences for, perceived value of, different types of VA interventions to improve access and quality Nearly 3,500 across US (= #s VA users, non-users) Women Veterans Cohort Study (OEF/OIF) Use, costs and satisfaction 2 yrs post-discharge and 2-yrs after coverage ends plus diagnosis/treatment of stress-related related conditions during coverage period

13 Dissemination and Implementation Women s health as a research priority VA as integrated health care system Real-life, life, real-time laboratory for implementing research into practice Large number of clinician researchers Staff physicians, psychologists, nurses, social workers etc. actively engaged in wide array of research Experience with patient population brought back to inform research activities Source:

14 Dissemination and Implementation Unusual degree of communication upward Accepted manuscripts notification and briefings Scientific portfolio manager focused on women vets Uptake fostered by research-clinical clinical-manager- policymaker partnerships Women Veterans Health Strategic Healthcare Group Center for Women Veterans Advisory Committee for Women Veterans Veterans Service Organizations VA Central Office leadership briefings Congressional testimony

15 VA Research into Practice/Policy: Enhanced Women s Primary Care Impact of practice structure on quality of care for women veterans Expert panel approach to reviewing results Briefings to Under Secretary (Feb 08) Charged Work Group w/developing guidance Briefings to managers/providers in the field VISNs (May 08), WVPM Leads (Jun 08), PC directors & WH managers (Jul 08), Advis Comm WV (Feb 09) W-CHIP (implementation plan) in process Source: Yano EM, Bean-Mayberry B, Washington DL. Impact of practice structure on the quality of care for women veterans. SGIM (May 2009), AcademyHealth (June 2009), manuscripts in preparation.

16 VA Research into Practice/Policy: PTSD Treatment for Women Veterans 1 st Cooperative Multi-site Trial of PTSD treatment for women veterans (CSP #494) Benefits of prolonged exposure therapy Briefings to VA Central Office, VA Office of Mental Health Services Multi-year rollout of prolonged exposure (PE) Creating national training infrastructure (clinical supervisors, trainers) Goal is to train t clinicians across US to use PE Source: Schnurr PP, Friedman MJ, Engel CC, et al. Cognitive behavioral therapy for posttraumatic stress disorder in women: A randomized controlled trial. JAMA. 2007; 297(8):

17 VA Research into Practice/Policy: Improving Gender Sensitivity Enhancing gender-aware care in VA Qualitative research designed intervention Conducted and published RCT demonstrating effectiveness of gender-aware curriculum No mechanism for implementation/spread through employee education system Currently, reappraising curriculum and using QUERI implementation research framework to foster adoption/implementation Source: Vogt DS, Barry AA, Kyng LA. Toward gender aware health care: Evaluation of an intervention to enhance care for female patients in the VA setting. J Health Psychol. 2008; 13(5):

18 ORD* Goals for Women s Health Research Collaboration with other organizations to develop women s research agenda Focus VA women s health research on veteran- related issues Encourage collaboration, communication and capacity-building among VA researchers interested in women s health Disseminate and implement research findings Position VA as a national leader in women s health research *ORD = VA Office of Research & Development

19 Future Research Needs Evaluate interventions for promoting provider skills/competency/comfort in women s health Test interventions to improve access/use Outreach/education, gender-sensitivity, homeless Coordination/navigation between VA and other care Evaluate quality of gender-specific care, equity Gender disparities in existing quality measures Develop/implement new gender-specific measures Quality of fee-basis and contract care in community Improve systems of care to meet diverse needs Women s clinics, mental health integration, telehealth Integrate peer support, family/caregiving issues

20 Future Research Needs Enhance inclusion of women veterans Supplemental funding to include women in research Educate researchers about their health/care needs Develop a women veterans practice-based research network (PBRN) Encourage women veterans to participate in research Create infrastructure to recruit/enroll women in trials Continue to educate researchers, providers, managers and policymakers Potential value of QUERI partnerships or center Workshops, cyberseminars,, listserv, weblinks

21 For More Information

22 Active Biomedical Women s Research Folate receptor-targeted targeted therapy for cervical cancer Estrogen receptor regulates c-jun c activity in breast cancer cells Cell-cell interactions during breast tumor angiogenesis: role of NRP-1 Role of atherogenic HDL & oxidative stress in ovarian cancer Targeting breast cancer metastases: role of chemokine heparinase Role of tissue transglutaminase in ovarian cancer Regulation of breast cancer growth by MLK-3 CARP-1: A potential therapeutic agent for breast cancer Actively targeted nanoparticulate paclitaxel to treat breast cancer

23 Active Biomedical Women s Research Role of Egr-1 1 in the function & fate of the corpus luteum 5-HT transporter function: interaction of hormones & antidepressants Lupus association with signal transducer & activator of transcription 4 mucosal immunity to HIV-1 Role of estrogen receptors in lupus-modulators of the inflammatory response Susceptibility genes in systemic lupus erythematosus Does demethylation of the inactive X predispose women to Lupus? The role of regulatory T-cells T in murine lupus

24 Active Biomedical Women s Research HIV-1 1 replication & transmission in the female reproductive tract Metabolic effects of androgenicity in aging men & women Estrogen receptor & cardiovascular function Breathing instability & upper airway obstruction during sleep Cytokine induced resistance to vitamin D Ovarian hormone regulation of behavior following traumatic stress Neurotoxic effects of alcohol: : effects of gender

25 Active Clinical Women s Research Understanding pain of gastrointestinal origin in women that serve in OEF/OIF Opioid medicated cardiac adaptation to stress Classical associative learning in male and female detoxified veterans Urine biomarkers of Lupus nephritis in Aspreva lupus management study Antibodies with prothrombin specificity in lupus The psychophysiology and neurobiology of PTSD across the menstrual cycle Neurobiology of severe psychological trauma in women

Health & Homelessness among Veterans: A Needs Assessment of HCH Grantees

Health & Homelessness among Veterans: A Needs Assessment of HCH Grantees Sarah Knopf-Amelung, MA-R Research Staff National Health Care for the Homeless Council Presentation Outline Literature Review Study