Faculty Bibliography

INTRODUCTION/BACKGROUND:Given the increasing number of women service members and veterans of childbearing age, it is important to understand the preconception risks in this potentially vulnerable population. This study compared the prevalence of modifiable preconception risk factors among women with and without a history of service. METHODS:Analyses included data from the 2013 and 2014 Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System. Preconception risk factors included health behaviors, chronic conditions, and mental health among women of childbearing age. Multivariate logistic regressions were used to compare the adjusted prevalence of each outcome among women with and without a history of service. Interaction terms assessed variation by age and history of service. RESULTS:Compared with women without a history of service, women with a history of service reported higher prevalence of insufficient sleep (49.6% vs. 36.3%; p < .001) and diagnosed depression (26.5% vs. 21.6%; p < .01). Women with a history of service were overall less likely to have obesity (19.8% vs. 26.5%; p < .001). Age-stratified results suggested that, compared with women without a history of service, women with a history of service were more likely to smoke in the 25 to 34 age group and reported comparable levels of obesity in the 35 to 44 age group. CONCLUSIONS:Women with a history of service demonstrated a preconception health profile that differs from women without a history of service. It is critical that providers are aware of their patients' military status and potential associated risks.

Preconception care (PCC), defined as a set of interventions to help women optimize their health and well-being prior to pregnancy, can improve pregnancy outcomes and is recommended by national organizations including the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists. Women Veterans who use the Department of Veterans Affairs (VA) health care system may face elevated risks of adverse pregnancy and birth outcomes due to a high prevalence of chronic medical and mental health conditions as well as psychosocial stressors including sexual trauma history and intimate partner violence. Many women Veterans of childbearing age experience poverty and homelessness, which are key social determinants of poor reproductive health outcomes. Furthermore, racial/ethnic disparities in maternal and neonatal outcomes are well documented, and nearly half of women Veterans of reproductive age are minority race/ethnicity. High-quality, equitable, patient-centered PCC services to address modifiable risks in this population are therefore a priority for VA. In this article, we provide a brief background of PCC, discuss the health risks of Veterans associated with adverse pregnancy outcomes, and highlight VA initiatives related to PCC. Lastly, we discuss implications and future directions for PCC research and policy within VA and across other health systems.

Caring for women with gynecologic malignancies requires multidisciplinary communication and coordination across multiple providers. This article discusses a rapid review of the literature on characteristics of care coordination for gynecologic malignancies. Five electronic databases (from inception through March 2015) were searched for empirical studies on coordinated care models for female adults with gynecologic malignancies. A single reviewer extracted and synthesized information on how care was coordinated, how care teams made decisions, who performed what tasks, how care teams communicated information to coordinate care, and potential impact of the characteristic on delivering coordinated care. From 26 included studies, predominant characteristics of coordinated care were identified: multidisciplinary teams, patient navigators, scheduled follow-ups, survivorship care plans, and colocated services. Decision-making was best documented for studies that utilized teams that had periodic scheduled meetings with set agendas and consistent procedures. Providers' roles in coordinating care were numerous, reflecting professional backgrounds: oncologists had most authority in making treatment decisions; radiologists and pathologists shared vital biomedical information; and nurses coordinated care and communicated with patients. Communication tools and strategies across studies included having shared medical records, integrated treatment plans, and telephone-based or teleconferencing communication. There was limited information available on the impact of characteristics and accompanying strategies or tools. Several characteristics of care coordination models for gynecologic cancers have been published in the literature. Further investigation is needed to understand the relative effectiveness of these ways to coordinate care.

Coordinating care between Veterans Health Administration (VA) and community providers is essential for providing high-quality comprehensive maternity care to women veterans, particularly those with chronic medical or mental health issues. We iteratively developed and assessed feasibility, as well as facilitators and barriers, of implementing the VA Maternity Care Coordinator Telephone Care Program, and identified specific health needs of pregnant women Veterans served by the program. We used three Plan-Do-Study-Act cycles. The final program consisted of materials supporting seven structured phone calls spanning initiation of pregnancy care through six weeks postpartum. We used logs to measure veteran uptake and surveys and field notes to capture care-coordinator perceptions about potential program value and facilitators and barriers to implementing it. We conducted a medical record review assessing pregnant veterans' need for coordination of services for physical and mental health problems and health behaviors. Veterans' uptake was 60%. Implementation facilitators included conducting training sessions for program coordinators and tailoring materials to address differences across VA facilities. Implementation barriers included limited information and communication technology tools to support the program and lack of coordinator time for delivering the telephone care. Among 244 pregnant veterans, 41% had pre-pregnancy chronic physical problem(s); 34% mental health problem(s); 18% actively or recently smoked. Implementation of a telephone-based care coordination program for pregnant veterans was feasible. Effective program spread required tailoring for local variations in resources and processes, investing in information and communication technology tools and allocating coordinator time to deliver care. Pregnant women veterans have a substantial burden of physical health, mental health, and risky health behaviors needing care coordination.

BACKGROUND: Prior studies demonstrate a higher prevalence of hysterectomy among veterans compared with nonveterans. While studies identify overall decreasing hysterectomy rates in the United States, none report rates of hysterectomy among women veterans. Given the increasing numbers of women veterans using Veterans Affairs health care, there is an ongoing need to ensure high-quality gynecology care. Therefore, it is important to examine current hysterectomy trends, including proportion of minimally invasive surgeries, among veterans using Veterans Affairs health care. OBJECTIVE: Our objective was to describe hysterectomy trends and utilization of minimally invasive hysterectomy in the Veterans Affairs healthcare system. STUDY DESIGN: This longitudinal study used Veterans Affairs clinical and administrative data from fiscal year 2008 to 2014 to identify hysterectomies provided or paid for by Veterans Affairs. Crude and age-adjusted hysterectomy rates were calculated by indication (benign or malignant), mode (abdominal, laparoscopic, vaginal, robotic assisted, unspecified), and source of care (provided vs paid for by Veterans Affairs). Mode and indication for hysterectomy were classified using International Classification of Diseases, ninth revision, codes. The distribution of hysterectomy mode in each year was calculated by indication and source of care. RESULTS: Between fiscal year 2008 and fiscal year 2014, the total hysterectomy rate decreased from 4.0 per 1000 to 2.6 per 1000 unique women veteran Veterans Affairs users. Age-adjusted rates of abdominal hysterectomy for benign indications decreased over the study period from 1.54 per 1000 (95% confidence interval, 1.40-1.69) to 0.77 per 1000 (95% confidence interval, 0.69-0.85) for procedures provided by Veterans Affairs and 0.77 per 1,000 (95% confidence interval, 0.69-0.85) to 0.29 per 1,000 (95% confidence interval, 0.23-0.34) for those paid for by Veterans Affairs. Among hysterectomies for benign indications provided by (n = 5296) or paid for (n = 2610) by Veterans Affairs, the percentage of hysterectomies performed abdominally decreased from 67.2% to 46.8% and from 68.9% to 57.6%, respectively. CONCLUSION: These findings suggest that gynecology care provided within Veterans Affairs has kept pace with national trends in reducing hysterectomy rates and increasing utilization of minimally invasive surgical techniques.

BACKGROUND: Little is known about contraceptive care for the growing population of women veterans who receive care in the Veterans Administration (VA) healthcare system. OBJECTIVE: To determine rates of contraceptive use, unmet need for prescription contraception, and unintended pregnancy among reproductive-aged women veterans. DESIGN AND PARTICIPANTS: We conducted a cross-sectional, telephone-based survey with a national sample of 2302 women veterans aged 18-44 years who had received primary care in the VA within the prior 12 months. MAIN MEASURES: Descriptive statistics were used to estimate rates of contraceptive use and unintended pregnancy in the total sample. We also estimated the unmet need for prescription contraception in the subset of women at risk for unintended pregnancy. For comparison, we calculated age-adjusted US population estimates using data from the 2011-2013 National Survey of Family Growth (NSFG). KEY RESULTS: Overall, 62% of women veterans reported current use of contraception, compared to 68% of women in the age-adjusted US population. Among the subset of women at risk for unintended pregnancy, 27% of women veterans were not using prescription contraception, compared to 30% in the US population. Among women veterans, the annual unintended pregnancy rate was 26 per 1000 women; 37% of pregnancies were unintended. In the age-adjusted US population, the annual rate of unintended pregnancy was 34 per 1000 women; 35% of pregnancies were unintended. CONCLUSIONS: While rates of contraceptive use, unmet contraceptive need, and unintended pregnancy among women veterans served by the VA are similar to those in the US population, these rates are suboptimal in both populations, with over a quarter of women who are at risk for unintended pregnancy not using prescription contraception, and unintended pregnancies accounting for over a third of all pregnancies. Efforts to improve contraceptive service delivery and to reduce unintended pregnancy are needed for both veteran and civilian populations.

BACKGROUND: Veterans concurrently using both Veterans Affairs (VA) and community providers and facilities have increased coordination needs related to bridging their care across health care settings. Women Veterans commonly require a combination of VA and community care if they have women-specific specialty care needs, such as gynecologic malignancies. OBJECTIVES: We assessed VA women's health providers' and administrators' perceptions of coordination challenges for Veterans' gynecologic cancer care, and potential approaches for addressing these challenges. RESEARCH DESIGN AND PARTICIPANTS: We carried out semistructured qualitative interviews with field-based key informants (VA gynecologists, women's health medical directors, and other staff directly involved in women's health care coordination) at 15 VA facilities. Transcripts were summarized in a template to capture key points. Themes were identified and iteratively revised (inductively/deductively) via a collaborative decision-making process utilizing matrices to compare content across interviews. RESULTS: Key informants (n=23) noted that services for patients with gynecologic cancers are provided through a combination of VA and community care with wide variation in care arrangements by facility. Care coordination challenges included care fragmentation, lack of role clarity and care tracking, and difficulties associated with VA and community provider communication, patient communication, patient records exchange, and authorizations. Care coordination roles suggested for addressing challenges included: care tracker, provider point-of-contact, patient liaison, and records administrator. CONCLUSIONS: Experiences in coordinating care for women Veterans with gynecologic malignancies receiving concurrent VA and community cancer care reveal challenges inherent in delivering care across health care systems, as well as potential approaches for addressing them.

Women with a history of sexual violence may face obstacles to obtaining preventive health services. Group education models have been used in other settings to improve knowledge and uptake of care. Focus groups were conducted to solicit the concerns and input of the subject population. Interdisciplinary group education sessions (GESs) were designed specifically to address concerns voiced in focus groups. GESs were conducted, addressing mammograms, pelvic examinations, and menopause, and emphasized preventive health education, as well as shared decision-making. GESs were audio recorded and qualitative feedback was collected immediately after each GES. Surveys were administered before and after each GES to evaluate attitude and knowledge change. A total of 18 women attended the focus groups, and 27 women attended at least one GES, with 12 women attending both. GESs were well received, and participants cited the education, group support, and healing dynamic as benefits of participation. Content knowledge improved after all three GESs. Attitude change showed a trend toward improvement, but the sample size was not large enough to detect statistical significance. Group education is an acceptable and feasible model among survivors of sexual violence. GESs improved knowledge among this small group of participants. GESs could be made available in a wide range of topics, as requested by our participants. Larger studies are warranted to examine long-term knowledge and attitude change after GESs.