Faculty Bibliography

BACKGROUND: Most US adults are overweight or obese. Understanding differences in obesity prevalence across subpopulations could facilitate the development and dissemination of weight management services. OBJECTIVES: To inform Veterans Health Administration (VHA) weight management initiatives, we describe obesity prevalence among subpopulations of VHA patients. DESIGN: Cross-sectional descriptive analyses of fiscal year 2014 (FY2014) national VHA administrative and clinical data, stratified by gender. Differences >/=5% higher than the population mean were considered clinically significant. PARTICIPANTS: Veteran VHA primary care patients with a valid weight within +/-365 days of their first FY2014 primary care visit, and a valid height (98% of primary care patients). MAIN MEASURES: We used VHA vital signs data to ascertain height and weight and calculate body mass index, and VHA outpatient, inpatient, and fee basis data to identify sociodemographic- and comorbidity-based subpopulations. KEY RESULTS: Among nearly five million primary care patients (347,112 women, 4,567,096 men), obesity prevalence was 41% (women 44%, men 41%), and overweight prevalence was 37% (women 31%, men 38%). Across the VHA's 140 facilities, obesity prevalence ranged from 28% to 49%. Among gender-stratified subpopulations, obesity prevalence was high among veterans under age 65 (age 18-44: women 40%, men 46%; age 45-64: women 49%, men 48%). Obesity prevalence varied across racial/ethnic and comorbidity subpopulations, with high obesity prevalence among black women (51%), women with schizophrenia (56%), and women and men with diabetes (68%, 56%). CONCLUSIONS: Overweight and obesity are common among veterans served by the VHA. VHA's weight management initiatives have the potential to avert long-term morbidity arising from obesity-related conditions. High-risk groups-such as black women veterans, women veterans with schizophrenia, younger veterans, and Native Hawaiian/Other Pacific Islander and American Indian/Alaska Native veterans-may require particular attention to ensure that systems improvement efforts at the population level do not inadvertently increase health disparities.

Objective To characterize the pregnancy outcomes of women Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans including prevalence of preterm delivery, low birth weight, and macrosomia, and to highlight methodological limitations that can impact findings. Methods A retrospective cohort study was conducted starting in 2014 analyzing data from the 2009 to 2011 National Health Study for a New Generation of US Veterans, which sampled Veterans deployed and not deployed to OIF/OEF. All pregnancies resulting in a live birth were included, and categorized as occurring among non-deployers, before deployment, during deployment, or after deployment. Outcomes included preterm birth, low birth weight, and macrosomia. The association of deployment with selected outcomes was estimated using separate general estimating equations to account for lack of outcome independence among women contributing multiple pregnancies. Adjustment variables included maternal age at outcome, and race/ethnicity. Results There were 2276 live births (191 preterm births, 153 low birth weight infants, and 272 macrosomic infants). Compared with pregnancies before deployment, pregnancies among non-deployers and those after deployment appeared to have greater risk of preterm birth [non-deployers: odds ratio (OR) = 2.16, 95 % confidence interval (CI) 1.25, 3.72; after deployment: OR = 1.90, 95 % CI 0.90, 4.02]. A similar pattern was observed for low birth weight. No association of deployment with macrosomia was detected. Discussion Compared with non-deployers, those who eventually deploy appear to have better pregnancy outcomes prior to deployment, but this advantage is no longer apparent after deployment. Non-deployers may not be an appropriate reference group to study the putative health impacts of deployment on pregnancy outcomes.

INTRODUCTION: Vasomotor symptoms (VMS), including hot flashes and night sweats, are common among postmenopausal women and are associated with reduced health related quality of life (HRQOL). PURPOSE OF THE STUDY: To determine whether Veterans are more likely to report VMS than non-Veterans, and whether the association of VMS with HRQOL varies by Veteran status. DESIGN AND METHODS: We used data from the Women's Health Initiative Observational Study, including self-reported baseline VMS presence and severity, and HRQOL at follow-up Year 3 (RAND Short Form 36-Item Health Survey). Employing generalized linear models we estimated whether Veteran status was associated with any VMS. We estimated the association between any VMS and HRQOL using linear regression, stratified by Veteran status. Interaction terms were added separately to determine whether the association varied by baseline depression, obesity, or smoking status. RESULTS: The final analyses included 77,153 postmenopausal women (2,004 Veterans). After adjustment, Veterans were no more likely than non-Veterans to report any VMS at baseline (relative risk [RR] 0.97, 95% confidence interval [CI] 0.90-1.04) or moderate to severe VMS (RR 1.03, 95% CI 0.89-1.18). Any VMS was associated with decreased HRQOL at Year 3, particularly among Veterans (mean difference range: Veterans -2.7 to -4.6, p-values < .001; non-Veterans -2.2 to -2.6, 95% CI -0.13 to -0.09, p values < .001). Baseline depression and obesity, but not smoking, amplified the negative association between VMS and HRQOL. IMPLICATIONS: Multicondition care models for postmenopausal Veteran and non-Veteran women are needed that incorporate management strategies for VMS, weight, and depression.

INTRODUCTION: Little is known about hysterectomy and bilateral salpingo-oophorectomy (BSO), which are associated with both health risks and benefits, among women Veterans. PURPOSE OF THE STUDY: To compare the prevalence of hysterectomy with or without BSO, and early hysterectomy, between postmenopausal Veterans and non-Veterans. DESIGN AND METHODS: We used baseline data from the Women's Health Initiative Clinical Trial and Observational Study. Multinomial logistic regression models examined differences in the prevalence of hysterectomy (neither hysterectomy nor BSO, hysterectomy without BSO, and hysterectomy with BSO) between Veterans and non-Veterans. Generalized linear models were used to determine whether early hysterectomy (before age 40) differed between Veterans and non-Veterans. Analyses were stratified by birth cohort (<65, >/=65 years at enrollment). RESULTS: The unadjusted prevalence of hysterectomy without BSO was similar among Veterans and non-Veterans in both birth cohorts (<65: 22% vs 21%; >/=65: 22% vs 21%). The unadjusted prevalence of hysterectomy with BSO was equivalent among Veterans and non-Veterans in the >65 cohort (21%), but higher among Veterans in the <65 cohort (22% vs 19%). In adjusted analyses, although no differences were observed in the >65 cohort, Veterans in the <65 cohort had higher odds of hysterectomy without BSO (odds ratio [OR] 1.18, 95% confidence interval [CI] 1.03, 1.36) and with BSO (OR 1.26, 95% CI 1.10, 1.45), as well as elevated risk of early hysterectomy (relative risk 1.32, 95% CI 1.19, 1.47), compared with non-Veterans. IMPLICATIONS: Aging women Veterans may have higher prevalence of hysterectomy and BSO than non-Veterans. This information contributes to understanding the health needs and risks of women Veterans and can inform clinical practice and policy for this population.

There are more than 2 million women veterans living in the United States. Many women do not identify themselves as veterans. As women's health care providers, it is important to understand and recognize the potentially complex health and social needs of women veterans and the role of military service on their lives. The reproductive health needs of women veterans may be shaped by their military experiences and coexisting medical or mental health conditions. Military sexual trauma and combat exposure are common causes of posttraumatic stress disorder and can affect overall health and well-being. Screening for military service is important in all women, and inclusion of this as a key demographic variable in research and clinical encounters can further inform health care considerations. The following key topics are addressed: who are women veterans, health and social risk factors associated with a history of military service, reproductive health across the life course, military sexual trauma and reproductive health of women veterans, how to take a military history, and the essential role of women's health providers, including obstetrician-gynecologists, in enhancing health systems and providing high-quality care to veterans.

BACKGROUND: Women veterans using Veterans Administration (VA) health care have high rates of medical and mental health comorbidities, placing them at increased risk of poor outcomes from unplanned pregnancy. Reproductive life planning is a strategy recommended by the U.S. Centers of Disease Control and Prevention that could promote healthy pregnancies and reduce unplanned pregnancy in the VA. However, no data exist on women veterans' perceptions of reproductive life planning discussions. METHODS: We trained six VA primary care physicians at two VA Women's Health Clinics to conduct reproductive life planning discussions with veterans aged 18 to 44 during primary care visits. After the visit, we performed semistructured telephone interviews with consenting veterans to explore perceptions of 1) reproductive life planning content and 2) provider-patient communication in reproductive life planning discussions. Interviews were audiorecorded, transcribed, and analyzed using content analysis. RESULTS: We interviewed 27 veterans with a mean age of 31 years (range, 22-42). Women veterans perceived generally reproductive life planning discussions as important opportunities to discuss reproductive goals with providers and to obtain new and relevant information about contraception, planning healthy pregnancies, and available VA reproductive health services. Perceptions of reproductive life planning content were influenced by women's pregnancy intentions. Perceptions related to provider-patient communication included preferences for provider-initiated discussions and nonjudgmental counseling that incorporates patients' values and preferences. CONCLUSIONS: Women veterans perceived reproductive life planning as valuable and important to their health. Reproductive life planning has the potential to enhance patient-centered delivery of reproductive health services in VA primary care.

OBJECTIVE: The number of women Veterans of childbearing age enrolling in Department of Veterans Affairs (VA) health care is increasing. Our objective was to describe characteristics of women veterans and resumption of VA care after delivery by use of VA prenatal benefits. STUDY DESIGN: We used data from the National Survey of Women Veterans, a population-based survey. VA-eligible women veterans with at least one live birth who had ever used VA and were younger than 45 years when VA prenatal benefits became available were categorized based on self-reported receipt of VA prenatal benefits. Characteristics of by use of VA prenatal benefits were compared using chi2 tests with Rao-Scott adjustment. All analyses used sampling weights. RESULTS: In our analytic sample, of those who potentially had the opportunity to use VA prenatal benefits, 25% used these benefits and 75% did not. Compared with women veterans not using VA prenatal benefits, those who did were more likely to be 18 to 24 years old (39.9% vs. 3.7%; p = .03), and more likely to have self-reported diagnosed depression (62.5% vs. 24.5%; p = .02) and current depression or posttraumatic stress disorder (PTSD) symptoms (depression, 46.1% vs. 8% [p = .02]; PTSD, 52.5% vs. 14.8% [p = .02]). Compared with women veterans not using VA prenatal benefits, those who did were more likely to resume VA use after delivery (p < .001). CONCLUSION: Pregnant women veterans who use VA prenatal benefits are a high-risk group. Among those who opt not to use these benefits, pregnancy is an important point of attrition from VA health care, raising concerns regarding retention of women veterans within VA and continuity of care.

BACKGROUND: Little is known regarding the reproductive health needs of women Veterans using Department of Veterans Affairs (VA) health care. OBJECTIVE: To describe the reproductive health diagnoses of women Veterans using VA health care, how these diagnoses differ across age groups, and variations in sociodemographic and clinical characteristics by presence of reproductive health diagnoses. RESEARCH DESIGN: This study is a cross-sectional analysis of VA administrative and clinical data. SUBJECTS: The study included women Veterans using VA health care in FY10. MEASURES: Reproductive health diagnoses were identified through presence of International Classification of Disease, 9th Revision (ICD-9) codes in VA clinical and administrative records. The prevalence of specific diagnosis categories were examined by age group (18-44, 45-64, >/=65 y) and the most frequent diagnoses for each age group were identified. Sociodemographic and clinical characteristics were compared by presence of at least 1 reproductive health diagnosis. RESULTS: The most frequent reproductive health diagnoses were menstrual disorders and endometriosis among those aged 18-44 years (n=16,658, 13%), menopausal disorders among those aged 45-64 years (n=20,707, 15%), and osteoporosis among those aged >/=65 years (n=8365, 22%). Compared with women without reproductive health diagnoses, those with such diagnoses were more likely to have concomitant mental health (46% vs. 37%, P<0.001) and medical conditions (75% vs. 63%, P<0.001). CONCLUSIONS: Women Veterans using VA health care have diverse reproductive health diagnoses. The high prevalence of comorbid medical and mental health conditions among women Veterans with reproductive health diagnoses highlights the importance of integrating reproductive health expertise into all areas of VA health care, including primary, mental health, and specialty care.

OBJECTIVES: To examine the association between on-site gynecology and availability of sex-specific services and policies in Department of Veterans Affairs (VA) emergency departments (EDs). RESEARCH DESIGN: Cross-sectional analysis using data from a VA national inventory of emergency services for women and gynecologist staffing information from the VA Office of Productivity, Efficiency, and Staffing. SUBJECTS: ED directors from all VA medical centers (N=120). MEASURES: We used logistic regression to evaluate the association between on-site gynecologist full-time equivalents (FTEs, <0.5 and >/=0.5), and availability of sex-specific ED services, such as consult and follow-up within VA by a gynecologist, emergency contraception, rho (D) immunoglobulin, pelvic ultrasound, and transfer policies for obstetric and gynecologic emergencies. All analyses were adjusted for number of ED encounters by women. RESULTS: Greater gynecologist FTE (>/=0.5 vs. <0.5) was associated with increased odds of on-site availability of a gynecology consultation in the ED [odds ratio (OR)=10.9; 95% confidence interval (CI): 3.2, 36.6] and gynecologist follow-up within VA after an ED encounter (OR=2.5; 95% CI: 1.0, 6.2). A positive trend was seen in availability of rho (D) immunoglobulin (OR=1.4; 95% CI: 0.6, 3.5) and presence of transfer policies for obstetric (OR=1.7; 95% CI: 0.7, 4.5) and gynecologic emergencies (OR=1.6; 95% CI: 0.6, 4.2). Half of the facilities with <0.5 FTE did not have transfer policies in place or under development. CONCLUSIONS: On-site gynecologist FTE is associated with improved availability of sex-specific care in EDs. Development of transfer processes for obstetric and gynecologic emergencies in settings with limited on-site gynecology is needed.

BACKGROUND: Visits to Veterans Administration (VA) emergency departments (EDs) are increasingly being made by women. A 2011 national inventory of VA emergency services for women revealed that many EDs have gaps in their resources and processes for gynecologic emergency care. OBJECTIVES: To guide VA in addressing these gaps, we sought to understand factors acting as facilitators and/or barriers to improving VA ED capacity for, and quality of, emergency gynecology care. RESEARCH DESIGN: Semistructured interviews with VA emergency and women's health key informants. SUBJECTS: ED directors/providers (n=14), ED nurse managers (n=13), and Women Veteran Program Managers (n=13) in 13 VA facilities. RESULTS: Leadership, staff, space, demand, funding, policies, and community were noted as important factors influencing VA EDs building capacity and improving emergency gynecologic care for women Veterans. These factors are intertwined and cross multiple organizational levels so that each ED's capacity is a reflection not only of its own factors, but also those of its local medical center and non-VA community context as well as VA regional and national trends and policies. CONCLUSIONS: Policies and quality improvement initiatives aimed at building VA's emergency gynecologic services for women need to be multifactorial and aimed at multiple organizational levels. Policies need to be flexible to account for wide variations across EDs and their medical center and community contexts. Approaches that build and encourage local leadership engagement, such as evidence-based quality improvement methodology, are likely to be most effective.